Are Key Examinations Being Missed? An Audit of Musculoskeletal, Neurological, and Cognitive Assessments in Geriatric Clerking

Introduction:

Thorough clinical evaluation is crucial in all specialties, but especially in geriatrics. Frailty, cognitive impairment, and reduced patient cooperation can obscure typical features, making diagnosis more challenging. Musculoskeletal, neurological, and cognitive assessments are particularly important for falls or confusion, where missed diagnoses such as delirium or fractures can worsen outcomes. This audit evaluated the quality of clinical examination during clerking and subsequent senior review on the Geriatric Assessment Unit (GAU), focusing on musculoskeletal, neurological, cognitive and mobility assessments by the multidisciplinary team within 24 hours.

Methods:

A retrospective analysis included data from 77 patients admitted to geriatric base wards via the GAU. An Abbreviated Mental Test Score (AMTS) assessed baseline cognition during clerking, and 4AT scores were used to screen for delirium, in line with NICE guidelines. Data were collected using paper-based clinical notes and digital 4AT scores. To address subjectivity, clear criteria were agreed to define adequate examination, and a second reviewer assessed borderline cases.

Results:

The audit found clinical examinations were often inadequate at first assessment. In initial clerking by a resident doctor, 51% of patients had adequate musculoskeletal assessment, 35% adequate neurological assessment, and 52% adequate AMTS. Senior review improved these to 69%, 40% and 57% respectively. 74% of eligible patients received a nursing or physiotherapy/occupational therapy assessment within 24 hours.

In a subgroup analysis of 31 patients presenting with a fall, 77% had adequate musculoskeletal examination: higher than the cohort average, suggesting greater adherence when clinically indicated. By contrast, among 16 patients presenting with confusion, 38% had AMTS completed, and 13% had adequate neurological assessment; no cases had both documented. Conclusion: Missed key assessments by junior and senior clinicians for falls or confusion may delay recognition of delirium or fracture, highlighting the need for targeted education and regular audits to improve adherence and patient outcomes.

Conclusion:

Missed key assessments by junior and senior clinicians for falls or confusion may delay recognition of delirium or fracture, highlighting the need for targeted education and regular audits to improve adherence and patient outcomes.