Fourth-Year Medical Student Charting of Older Persons' Cognitive and Functional Status

Area of Science:

• Geriatric Medicine
• Medical Education
• Health Informatics

Background:

• Functional and cognitive impairment significantly impact medical outcomes in older adults.
• Inadequate documentation of these impairments in medical records is a persistent challenge.
• Accurate charting is crucial for comprehensive patient care and management.

Purpose of the Study:

• To assess the charting performance of fourth-year (M4) medical students regarding cognitive and functional status in older patients.
• To evaluate documentation practices during non-geriatric clerkships.
• To identify areas for improvement in medical student training and electronic health record utilization.

Main Methods:

• Retrospective chart review using a specialized audit tool.
• The tool identified documentation related to delirium, chronic cognitive impairment, activities of daily living (ADLs), and instrumental activities of daily living (IADLs).
• Keywords and phrases were used to prompt research assistants during chart abstraction.

Main Results:

• Medical students documented acute cognitive status (ACS) in 57% and chronic cognitive impairment (CCI) in 68% of cases.
• Physicians and nurses demonstrated higher documentation rates for ACS (63%) and CCI (84%).
• Documentation of ADLs (31%) and IADLs (3%) by students was lower than by physicians/nurses (59% and 0%, respectively).

Conclusions:

• Student and physician documentation of cognitive status in hospital charts exceeded some literature reports, potentially due to curriculum integration of geriatrics.
• Documentation for ADLs was superior to IADLs for both students and physicians.
• Overall documentation of IADLs remains a significant area for improvement.