title: Fourth-Year Medical Student Charting of Older Persons' Cognitive and Functional Status.
abstract: OBJECTIVE
  Functional and cognitive impairment correlates with medical outcomes in older persons, yet documentation in the medical record is often inadequate. The purpose of this pilot study was to evaluate fourth year (M4) medical students' charting performance of cognition and functional status in older persons during non-geriatric clerkships using an audit tool.
  
  
  METHODS
  The research assistants used a chart abstracting tool to retrospectively review patients' charts. The abstracting tool contained keywords and phrases to prompt the research assistants to look for any documentation of patient status in four domains: (1) delirium or acute confusional state, (2) chronic cognitive impairment, (3) activities of daily living, and (4) instrumental activities of daily living. The threshold was any mention of keywords in these domains.
  
  
  RESULTS
  On non-geriatrics M4 clerkships in the hospital, students documented acute cognitive status (ACS) and presence or absence of chronic cognitive impairment (CCI) in 57% and 68% of cases respectively, with physicians and/or nurses doing it more often at 63% and 84%. Both students and other care providers documented ACS and CCI in the same charts 41% and 59% of the time, respectively. Students documented activities of daily living (ADLs) and instrumental activities of daily living (IADLs) 31% and 3% respectively, physicians and/or nurses 59% and 0%.
  
  
  CONCLUSIONS
  Documentation of cognitive status in hospital charts for students and physicians was somewhat higher than in the literature. This may be because geriatrics is integrated into our 4-year curriculum. Documentation by both students and physicians was better for ADLs than IADLs and poor for IADLs overall.
authors.affiliation: Department of Geriatrics, Florida State University.
authors.forename: John
authors.initials: J
authors.lastname: Agens
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Appelbaum
authors.forename: Suzanne
authors.initials: S
authors.lastname: Baker
authors.forename: Kenneth
authors.initials: K
authors.lastname: Brummel-Smith
authors.forename: Eli
authors.initials: E
authors.lastname: Friedman
authors.forename: Suzanne L
authors.initials: SL
authors.lastname: Harrison
authors.forename: Mitchell
authors.initials: M
authors.lastname: Kutner
authors.forename: Jonathan
authors.initials: J
authors.lastname: McKenzie
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D060825:Cognitive Dysfunction; D003479:Curriculum; D004282:Documentation / Q000592:standards; D004504:Education, Medical, Undergraduate; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D012189:Retrospective Studies; D015144:Southeastern United States; D013337:Students, Medical; D011795:Surveys and Questionnaires