Documenting Communication and Cognitive Function

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care.

Guidelines for General Observations


SpeechSpeaks clearly in English (or other spoken language)
Speaks with only one-word responses; does not respond to verbal stimuli
Speech is slurred, hearse, loud, soft, incoherent, hesitant, slow, fast, or nonsensical
Has difficulty completing sentences due to shortness of breath or pain.
HearingHears well enough to respond to questions
Hard of hearing; wears hearing aid; must speak loudly into left or right ear.
Deaf; reads lips or uses sign language
VisionSees well enough to read instructions in English or other language
Wears corrective lenses to see or to read
Cannot read.
Blind (one eye or both)

Cognitive functions

AwarenessOriented x 3 and aware of surroundings and situation
Disoriented; unaware of time, place, person, or situation
MoodResponds appropriately; talkative
Answers in one-word responses; offers information only when asked direct questions
Hesitates in answering questions; looks to family or support person before answering
Angry; states “Leave me alone” (use quotations to record what they say); speaks loudly and abruptly to family or support person(s).
Maintains or avoids eye contact
Thought processesMaintains a conversation; makes relevant statements; follows commands appropriately
Mind wanders; makes irrelevant statements; follows commands inappropriately.


Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

  • Have a claim made against your professional services.
  • You will be named in a group lawsuit – whether as part of a larger group of health care professionals and/or included with your health care facility.
  • Witness a negligent act by another health care professional during the course of a normal work day.
  • Be deposed to testify on behalf of yourself, your employer or colleague.

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties. However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy. It is important to understand the most common allegations and how they happen in order to minimize your risk. Most malpractice calms involve at least one of the following allegations:

  1. Failure to follow standards of care
  2. Failure to use equipment responsibly
  3. Failure to document
  4. Failure to assess and monitor the patient
  5. Failure to communicate.


I will discuss these five common allegations in the coming blog posts, so stay in touch!

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