Documentation of a dementia diagnosis and identified causes in a patient’s visit notes and problem list is essential to support continuous follow-up care. Primary care providers also need to include this information in the electronic health record (EHR) to coordinate the care of individuals living with dementia who frequently transition across settings (Callahan et al., 2012; Callahan et al., 2015). Primary care teams should consider instituting routine documentation of dementia diagnoses and including relevant check boxes in the EHR.

Practice Pearl | Documenting the Diagnosis

Laura Medders, LCSW, Administrative Director, Emory Integrated Memory Care


By having a clear diagnosis and stage documented, other Integrated Memory Care team members, like the registered nurses and social workers, can recommend interventions and support that should be more closely aligned with the person living with dementia’s current level of functioning. For example, the social worker would not recommend a frozen meal delivery service if they know the individual can no longer operate a microwave.

“Documentation of a dementia diagnosis and identified causes is essential to support continuous follow-up care.”


Evaluate | Approaches to Implement

Diagnostic Overview | Explain the Importance of a Diagnostic Evaluation | Components of a Diagnostic Evaluation | Culturally Competent Approaches to Evaluations | Identify Conditions Underlying Dementia | Document the Diagnosis | Disclose the Diagnosis | Evaluate References