The Practical Neurological Examination, Part 1
Assessment of Mental Status
By K. Jeffrey Miller, DC, MBA
There are six standard components of a neurological examination: mental status, cranial nerve, coordination, motor, sensory and reflex testing. While they are standards in medical neurology, the same does not apply in chiropractic practice. Chiropractors are trained to test these standard components, but they seldom do so consistently. Of the six components, motor, sensory and reflex testing dominate chiropractic examinations, while mental status, cranial nerve and coordination testing are secondary and in some cases nonexistent. (This last statement is based on my many years of peer-review and malpractice defense work.)
This article is the first of six written to provide practical knowledge and examples of how to incorporate all six components into a standard examination in an efficient and productive manner. Let's focus first on mental status, or as it is often referred to as, higher cortical function.
Evaluating Mental Status
Mental status examination is concerned with the patient's orientation to person, place and time; general information; short and long-term memory; spelling; and the use of numbers. This sounds like a great deal of testing to undertake, and it can be (for good reason) if the patient is suspected of having an altered mental status. However, a good screening of mental status is much easier than it sounds.
In the fourth edition of How to Examine the Nervous System, R. T. Ross states, "The majority of patients seen by a neurologist do not require testing of intelligence. In the course of history taking the patient's memory and intelligence are revealed and this is often sufficient." Despite the reference to neurologists, the same can be said for patients seen by a chiropractor.
So, what's the big deal? There are three issues. The first for the doctor is being able to identify, if asked, what it was that assured them that the patient's mental status was intact. The second concerns documenting these facts. Were they recorded in the patient's record? The third issue involves how mental status relates to informed consent.
The majority of initial interactions and conversations a doctor has with a patient are considered normal, meaning the patient has no difficulties understanding or responding to questions. Despite pain and anxiousness regarding the presenting problem, the history process was a reasonable exchange of information.
But what exactly are the interactions that make up a "normal" encounter and provide proof of "normal" mental status? The patient's completion of the initial history and financial forms in the reception room prior to seeing the doctor is a major factor. If the patient printed and signed their own name on the form, they are oriented to person. If the patient provided appropriate information to health-related questions, they are orientated to person and place because they know they are in a doctor's office. The patient is also orientated to place by finding their way to the office. If the patient made the appointment, showed up on time, dated the forms correctly, provided a timeline for their present illness or injury and provided dates for past health events (injuries, surgeries), they are oriented to time.
Questions on the history forms regarding past illness and injury and current complaints help assess short- and long-term memory. Chit-chat between the doctor and patient during the history can help identify the patient's recognition of current events and general information. The doctor can simply ask in a friendly manner about the patient's family, work, hobbies, etc.
The patient's ability to spell, as reflected by the information provided on the entrance forms, helps in assessing their ability to use words. This can also be determined in the verbal interactions the patient has with the doctor and staff.
One of the few components of the mental status examination that cannot be assessed from the patient's entrance forms and oral history is the use of numbers - although skill with numbers can sometimes be ascertained by watching and listening to the patient when the details of their insurance coverage or lack thereof are detailed.
There are exceptions here. The patient may not have completed the paperwork alone; they may have had help or another person may have completed the paperwork entirely. The patient may also have poor reading and writing skills. In these situations, obviously the doctor must look further and perform more complete testing.
The above observations become so mundane during the course of practice that unless they are out of the ordinary, they go unmentioned and undocumented. These observations are part of the art of practice.
Document Your Observations
A simple checklist following the history to confirm the observations would be a great addition to the patient record. Another way to document it on the patient record would a statement such as, "Based on the patient's completion of the initial paperwork/history and their interaction with doctor and staff during the history and examination process, patient's mental status appears to be within normal limits."
Recording normal mental status is important. Being able to explain how it was determined is just as vital. Someone will eventually ask. Recording the patient's mental status is important both clinically and legally. For example, let's say there are two malpractice cases involving plaintiff claims that they did not give informed consent for care. In the first case, the plaintiff claims that tests and treatments were never explained to her appropriately. In the second case, the plaintiff's family claims that the plaintiff was not capable of giving informed consent due to a deficient mental status.
Both of these malpractice cases would be hard battles, especially the latter, as most doctors could not offer proof that mental status was assessed or taken into consideration. But the information is usually there, on the forms and via the initial patient interaction. Doctors must remember where the information is established in the record and correlate it appropriately.
In cases in which it is obvious from the history and entrance forms and the doctor and staff's initial interaction that the patient's mental status is intact, no additional procedures are necessary. Additional time is not required over the usual examination process. In cases in which mental status does raise questions, additional testing is required. The results are recorded and this information is considered in relationship to consent, continuation of care or patient referral. If obtaining consent from the patient does not appear to be possible, then the doctor must seek it from a relative or guardian.
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