Step 01
Clinician input
67-year-old male, post-op day 4 from cardiac valve replacement, acute confusion, agitation, fluctuating attention, sleep-wake reversal. Current meds and labs included.
Step 02
Differential & formulation
Ranked differential led by delirium (hyperactive subtype), with organic etiologies surfaced — electrolyte, infection, medication-induced, hypoxia.
Step 03
Medication safety check
Anticholinergic burden, QTc-prolonging combos, renally-cleared agents flagged. Recommended monitoring surfaced.
Step 04
Risk & disposition
Structured agitation risk, capacity considerations, monitoring intensity, and admission-versus-step-down framing.
Step 05
Documentation draft
Chart-ready note with ICD-10 (F05 — delirium), CPT (99233), and embedded medical-necessity language. Clinician reviews, edits, signs.
Step 06
Provenance & confidence
Every output exposes its source set and a confidence indicator. “Why this consideration” expanders show supporting reasoning.