Nursing documentation versus standardized assessment of cognitive status in hospitalized medical patients

Appl Nurs Res. 2000 Feb;13(1):29-36. doi: 10.1016/s0897-1897(00)80016-6.


Although the literature discusses the importance of assessing cognitive status, little research has explored the concordance of nurses' documentation of cognitive status and standardized assessment. This study examined nurses documentation of cognitive status in 42 medically hospitalized individuals (mean age 51.9, SD = 10.1 years) using a variety of standardized measures. Although the chart review revealed no documentation of impaired cognitive status, impaired performance in 24 to 67% of the cognitive measures was identified. This study suggests nurses are missing cognitive impairment in hospitalized patients by limiting assessment to orientation. Use of a combination of several brief screening measures, such as the Clock Drawing Test and the standardized Mini-Mental State Examination, would provide timely, effective, and inexpensive assessment of cognitive status.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Cognition Disorders / diagnosis*
  • Cognition Disorders / nursing*
  • Female
  • Humans
  • Inpatients*
  • Male
  • Mass Screening / methods
  • Mental Status Schedule
  • Middle Aged
  • Neurologic Examination / methods*
  • Neuropsychological Tests
  • Nursing Assessment / methods*
  • Nursing Assessment / standards*
  • Nursing Audit
  • Nursing Evaluation Research
  • Nursing Records / standards*
  • Orientation
  • Prospective Studies
  • Time Factors