Cognitive Mental Status

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Trace DC33-10

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Subjective — ask

  • Memory or confusion concerns from the patient and the caregiver, and the onset and course (acute and fluctuating versus gradual).
  • Specific lapses — missed medications, getting lost, repeating questions, or difficulty with familiar tasks.
  • The functional impact — effect on medication management, finances, and activities (detail in Function).
  • Behavioral and psychological symptoms — agitation, suspiciousness, hallucinations, or sleep-wake disturbance.
  • Any acute precipitant — a new medication, infection, dehydration, or recent illness.
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