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Reader Question:

A Patient With Memory Deficits May Tax Your Memory, Too

Published on Sun Jan 25, 2004

Here's what you need to document.

Question: What are important things to document when you're caring for a patient with memory deficits?

Answer: Memory deficits affect how you provide service to a patient who may be unable to remember what you're trying to teach, advises Laura Gramenelles with Hamden, CT-based Simione Consultants. Be sure there is a caregiver available to the patient, especially regarding medications or teaching about activities such as wound care. Observe the patient and interview both the patient and the caregiver.

Clinicians should include the following information in the clinical record, Gram-enelles suggests:

  • a description of the memory deficit and what effect it has on the care you are providing;

  • a determination of how much the patient can remember;

  • the patient's decision-making abilities, based on asking him to make a decision;

  • any changes in the patient's ability to perform ADLs and IADLs;

  • any paranoid behavior or difficulty in getting the patient to stop socially inappropriate activities;

  • any safety issue the patient's behavior is creating;

  • any verbal disruptions or physical aggression;

  • any delusions or hallucinations you observe or the caregiver reports;

  • behaviors that occur when you are not there but are reported by caregivers or family members; and

  • the patient's level of alertness and orientation, comprehension, concentration and short-term memory.

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