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This section is designed to capture the clinically pertinent positive and negative elements of what the patient talks about. Suicidal ideation, intent, and plan, as well as homicidal ideation, intent, and plan are included in this section. As mentioned previously, perceptual disturbances and how they affect the patient can also be included in this section.

Orientation

This section describes the patient’s ability to state the following information:

  • ? The patient’s full name
  • ? Date of birth
  • ? Their current location (what kind of a place they are in, what the name is of the place, what floor of the hospital they are on)
  • ? The time of day
  • ? Current date including month and year
  • ? Why they were brought to or came to the ED (e.g., “What brings you to the ED?”)

Documentation should reflect if prompting is required, or if there are any errors in their answers, regardless of how minor.

Memory

This section should provide a brief overview of the patient’s ability to answer questions regarding recent, remote and immediate recall. A test of the patient’s memory is valuable in determining any cognitive deficits, including symptoms of a neurocognitive disorder. A simple test of the patient’s memory can be completed by asking the patient to remember three items you ask them to remember. Typically, this is done by telling them three things (such as apple, ball, penny), and asking the patient to repeat the words. The clinician then tells the patient to remember them and that they will ask them to repeat the words in a couple of minutes. This is a good test for short-term memory recall, and when documented can be used as a “baseline” for the subsequent times the same memory test is given.

To test recent memory, we typically ask what the patient has had for breakfast that morning. The trick to this is to make sure you can corroborate the truth of the information given either from ED staff, a family member, or patient caregiver.

Remote memory can be tested by asking for personal historical information, or past experiences. This also needs to be corroborated with others that know the patient’s history to ensure accuracy.

 
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