Restlessness and agitation
ICD-10 R45.1 is a billable code used to indicate a diagnosis of restlessness and agitation.
Restlessness and agitation are symptoms characterized by an inability to remain still, often accompanied by feelings of anxiety or unease. Patients may exhibit physical signs such as fidgeting, pacing, or an inability to focus. These symptoms can arise from various underlying conditions, including psychiatric disorders (e.g., anxiety disorders, schizophrenia), neurological conditions (e.g., Parkinson's disease, dementia), or as a side effect of medications. Clinical assessment typically involves a thorough history and physical examination, focusing on the onset, duration, and context of the symptoms. Laboratory tests may be warranted to rule out metabolic or infectious causes. Understanding the patient's overall clinical picture is crucial for appropriate management and treatment planning.
Detailed patient history, including medication review and psychosocial factors.
Patients presenting with anxiety, insomnia, or side effects from medications.
Consideration of comorbid conditions such as depression or chronic illness.
Acute assessment notes, including vital signs and immediate interventions.
Patients presenting with acute agitation due to substance use or withdrawal.
Rapid assessment and intervention are critical; documentation must reflect urgency.
Used when evaluating a patient with restlessness and agitation in an outpatient setting.
Document history, examination findings, and treatment plan.
Internal medicine may focus on underlying medical causes, while psychiatry may focus on mental health aspects.
R45.1 should be used when a patient presents with restlessness and agitation without a specific underlying diagnosis. It is important to document the context and any contributing factors.
