Cognitive Mental Status

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Trace DC33-3

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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2. What the clinician must assess

A complete assessment addresses each of the following each visit, scaled to the patient's diagnosis and stability:

  • Orientation — to person, place, time, and situation.
  • Memory — recent (short-term) and remote.
  • Attention and concentration.
  • Executive function — planning, judgment, and problem-solving.
  • Language and communication as they relate to cognition (detail in Communication).
  • Level of consciousness and alertness.
  • The acuity and course — acute onset and a fluctuating course (a delirium concern, to evaluate urgently) versus a chronic and progressive course (dementia) — and behavioral and psychological symptoms.
  • The impact on safety, medication management, and decision-making capacity (cross-linked to Safety and Function), and any change from the patient's baseline.
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