Yes. Fluctuating consciousness is the hallmark of delirium, and a patient who appeared confused on the night shift may appear relatively normal during morning rounds. This apparent normalization is not reassurance — it is characteristic of the condition. The positive DOSS from the prior shift should prompt formal CAM assessment regardless of current apparent lucidity, a physician review to identify precipitating causes (infection, metabolic abnormality, medication effects, urinary retention, pain), and implementation of delirium management protocols. Document both the positive DOSS and the apparent improvement at the time of assessment.

For patients with baseline dementia, interpret DOSS relative to their established baseline behavior rather than against cognitive-intact norms. If possible, establish an early-admission DOSS baseline (when the patient is at their best cognitive state) and use this as a reference. An increase of 2 or more points above baseline in a patient with dementia suggests superimposed delirium, even if the absolute score is below the 3-point threshold. Contact family members or caregivers to establish what behaviors represent a change from home baseline, and document their input in the assessment.

A positive DOSS (score 3 or higher) should initiate a systematic clinical response: (1) nurse notifies charge nurse and attending physician or NP; (2) formal delirium diagnostic assessment using CAM or 4AT within 1-2 hours; (3) medical review to identify precipitating factors including infection workup, electrolytes, blood glucose, urinalysis, medication review for new or recently changed deliriogenic drugs, assessment for urinary retention and constipation, pain evaluation, and oxygenation status; (4) initiation of non-pharmacological delirium management including reorientation, sleep optimization, mobilization, and sensory aids; (5) documentation of actions taken and outcome in nursing notes.

DOSS was primarily validated in inpatient settings with serial nursing observation across shifts. In the emergency department, the rapid patient throughput and different care workflow make serial shift-based DOSS less practical. For ED delirium screening, faster tools such as the [4AT](/tools/4at-delirium) or [UB-2](/tools/ub-2-delirium) are generally more appropriate for initial triage. However, for patients spending extended periods in ED observation or holding areas, DOSS-style nursing observation can supplement faster screening tools and provide additional sensitivity for hypoactive delirium.

The original DOSS protocol specifies one observation per 8-hour shift, yielding three assessments per 24-hour period. This three-times-daily frequency is optimal for capturing the characteristic temporal fluctuation of delirium, including hypoactive episodes that may occur predominantly at night. Once-daily DOSS significantly reduces sensitivity, particularly for hypoactive delirium and fluctuating presentations. In high-risk patients (age 70+, known dementia, post-operative day 1-3), all-shift completion is recommended. In lower-risk patients, at minimum morning and evening shift completion captures most clinically significant episodes.