Documenting Mental Status

[Dustdevil]

Good responses above.

If they are "conscious, alert, and fully oriented", then that is exactly what I chart, word for word. No abbreviations or "x" numbers used, as this is obviously too ambiguous, seeing that so many people use different standards for their assessments.

If they lack any element of orientation, then I chart exactly what they are and are not oriented to. Again, the use of any "x" number abbreviation is meaningless, as it does not give the reader any idea of the patient's orientation, which is really the point, isn't it?

My advice, forget all this x3 and x4 nonsense altogether and write what you mean.

[FormerEMSLT297]

Good responses above.

If they are "conscious, alert, and fully oriented", then that is exactly what I chart, word for word. No abbreviations or "x" numbers used, as this is obviously too ambiguous, seeing that so many people use different standards for their assessments.

If they lack any element of orientation, then I chart exactly what they are and are not oriented to. Again, the use of any "x" number abbreviation is meaningless, as it does not give the reader any idea of the patient's orientation, which is really the point, isn't it?

My advice, forget all this x3 and x4 nonsense altogether and write what you mean.

Dust is correct, with so many abbreviations what do they really mean ..?????...

Example APE--- does it mean Acute Pulmonary Edema.??? or Acute Pulmonary Embolus.???... I could go on and on , but if the form has a GCS listed I fill in the proper number 15, 14, (or break it down 4,5,6)whatever.... but for my narrative, I write out ,, patient conscious and alert, to person, place, time and surroundings. Now if they aren't,, I'll put, when asked patient thought Bill Clinton was President, When asked the season she thought whatever. Or just put patient did not respond verbally to questions....

[JCicco345]

I agree with dust and former about documenting your actual assessment instead of using numbers. If you have paperwork like ours you have a box for the cao stuff, so if you need to put a number in their, make sure you write out your actual mental status assessment in your narrative. For the patient you described i would write exactly what you did. As for the number, if its needed, use the 4 questions for person, place, time, event. The only problem is with a patient like you described where they are presenting with stroke like symptoms its hard to tell because the garbled speech isn't necessarily a wrong answer. They usually know what they want to say but just can't express it. Personally in the cao box, i just put "see narrative" across it and then document something like, patient responded to all questions with garbled and incoherent speech. Hope that helps.