In the medical field, A&Ox4, A/Ox4 or AOx4 means the patient is alert and oriented to person, place, time, situation.
This short mental status exam (MSE) for level of orientation is part of a neurological exam. It may be used in psychology and medicine by a psychiatrist, psychologist, doctor, nurse, medical assistant, social worker or emergency medical technician (EMT).
Many medical offices and facilities only use the first three questions to observe AOx3 status for person, place and time. Many medical personnel believe that alert and oriented x3 indicates a completely normal level of consciousness and orientation, indicating medical capacity to make decisions regarding medical treatment.
Some facilities may use five questions, including identifying an object to observe AOx5.
Based on the alert and oriented mental status exam, a different course of action may be advised or followed.
Level of Consciousness
A patient’s level of awareness may be categorized as:
1. Awake, Alert – eyes open, interactive, responsive
2. Lethargic – sleepy, drowsy, arousable then responsive
3. Obtunded – difficult to arouse, arousable with repeated stimulation
4. Stuporous – semi-comatose, arousable with vigorous stimulation
5. Comatose – cannot be aroused, no response, no interaction with surroundings
Alert and Orientated to Person, Place, Time and Situation
Orientation can be determined with the following questions.
1. Person– What is your name? When is your birthday? Who is this family member/friend/person next to you?
2. Place– What building, floor, city, county, state are we in?
3. Time– What is the month, date, year, day of week, season?
4. Situation (or event)– Why are you here? What happened?
5. Object/item– What is this object/item? (a book, telephone, and penny are commonly used)
Ask simple open-ended questions that require thinking and reasoning to form an answer. Do not ask closed-ended questions that may be answered yes or no.
If the signer is alert and answers all 4 questions correctly, you can make a notation of “AOx4” in the notary journal. If they cannot answer a question, make a notation such as “AOx3, except date” to indicate they are not aware of the current date.
Dementia is a condition with deterioration in two or more areas of memory, language skills, ability to focus and pay attention, ability to reason and problem-solve, or visual perception, affecting the ability to perform everyday activities. Mild cognitive impairment includes some memory or thinking difficulties, but not severe enough for a diagnosis of dementia.
The mini mental state examination (MMSE), is a 10-minute, 30-point questionnaire, and the most commonly used test for dementia. A score of 24 or more (out of 30) indicates no cognitive impairment, 19-23 points mild impairment, 10-18 points moderate impairment, and 9 points or less, severe impairment. Free versions of the test are available on the internet. See mini mental state examination.
Orientation to person is the last element of orientation to be lost, usually only in severe dementia or in psychotic states. Orientation to time and place are usually lost before person orientation. An Alzheimer’s patient may become confused about place and time, wander away and get lost. Impairment in orientation and memory are found consistently in Alzheimer’s. Patients with other dementia often maintain orientation but memory is impaired.
Alzheimer’s patients comprise 50% to 70% of dementia cases, followed by vascular dementia caused by stroke (25%), Lewy body dementia (15%), and frontotemporal dementia (2% to 5%). Less common causes of dementia include head injury, Huntington’s disease and Parkinson’s disease dementia in about 50% to 80% of Parkinson’s patients.
About 3% of people between the ages of 65-74 have dementia, 19% between 75 and 84 and nearly 50% of those over 85 years of age.
In Colorado, in 2016, there were about 10,000 Alzheimer’s patients age 65-74, 28,000 patients age 75-84, and 28,000 patients age 85 or older, for a total of 67,000. The total is expected to grow to 92,000 by 2025.
The Colorado Probate Code defines an incapacitated adult as an adult “who is unable to effectively receive or evaluate information or both or make or communicate decisions to such an extent that the individual lacks the ability to satisfy essential requirements for physical health, safety, or self-care, even with appropriate and reasonably available technological assistance.”
A person with dementia may have a lucid interval due to medication, hydration, diet, vitamins, stimulus, and other factors, when they can understand, make rational decisions and communicate. Different types of dementia involve different parts and functions of the brain.
Nature of the Act, Consequences
Some law firms consider a score of AO3 or AO4 as likely alert and aware enough to show legal capacity to sign legal documents, but lower scores should be declined or rescheduled for a better time when the signer is more alert, rested or better oriented after taking medication, drinking coffee, walking or exercising. Family members may be able to recommend the best time to sign documents.
For legal documents, the principal must understand the nature of the act and its consequences, at the time of execution, and must sign voluntarily. The level of capacity required varies by the type of document: testamentary capacity for a last will, or contractual capacity for contracts.
Testamentary capacity requires sound mind including awareness of the extent of property owned and the family members, including all children (natural objects of their bounty), the natural heirs. Colorado courts define sound mind as presence of the Cunningham Test elements and absence of the Insane Delusion Test elements.
For an acknowledgment, “acknowledged before me” means that the signer appeared before the notary, acknowledged that he/she executed the instrument for the purposes stated therein, and by proper authority.
If the notary has information or reason to believe the signer has a mental impairment or diminished capacity, the notary can ask probing questions to determine legal capacity.
Has a doctor made a diagnosis that you are mentally incapacitated? Has a court made a ruling that you are mentally incapacitated?
Are you over the age of 18? What is the title of this document? What is the nature and purpose of this document? What are the consequences and effect of signing this document? [See Blackmer v. Blackmer, 525 P.2d 559 (Mont. 1974)] The notary should not probe into the private contents of the document or quiz the signer on the comprehension of the document.
Is the signer acting rationally in his/her own best interest? A delusion does not mean incapacity if it does not materially affect the nature and consequences of the document or transaction.
The notary should decline to notarize if the signer does not appear to have legal capacity at the moment, or if the notary knows the person has been adjudged as mentally incapacitated by a court and legal capacity has not been restored.
If there is a witness, ask the witness if he/she believes the signer is of sound mind and appears to understand the nature and consequences of signing the document. A witness could sign a notarized affidavit.
With permission, the transaction may be recorded on video for evidence of the signer’s legal capacity.
HIPAA Privacy Rule
Do not ask health care providers to disclose private medical records or protected health information unless there is a HIPAA release form authorizing you to see or use the private information. HIPAA imposes financial penalties for improper disclosure of private medical information.
The HIPAA Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.
Note: Laws vary by state. Colorado laws regarding privacy, copies and inspection of medical records are found at CRS 25-1-801. Patient records in custody of health care facility.
If your notary journal is open to public inspection, do not record any protected health information in the journal. If the journal is not open to public inspection, if you record any protected health information, you can use a coding system to enter cipher text, rather than plain text.
For example, instead of writing AO4, the entry might read 414F34, based on the Unicode character numbers, or some other coding system that you choose or create. Keep the notary journal secure and cover unrelated journal entries during notarization to maintain privacy.
Registration and Recall Memory Test
In addition to an alert and oriented exam, a registration and recall memory test is used to assess the ability to remember information. Three words, often book, telephone, and penny, are given to the patient to remember.
The patient is instructed to repeat the three words and told they will be asked to recall the three words again in a few minutes. Then, after 3-5 minutes involving another activity (see serial sevens test below), the patient is asked to recall the three words. One point for each correct answer.
Attention and Calculation Test
Serial sevens, counting down from one hundred by sevens, is used to test attention and calculation ability. Five points maximum, one point for each correct answer, 100, 93, 86, 79, 72, 65.
Notary Check for Alert and Oriented, Legal Capacity
Awareness and orientation questions are especially important for a patient or signer with a head injury or brain disease, Alzheimer’s, stroke, dementia, or person under the influence of drugs or alcohol.
While a notary is a lay person, not a medical professional, and does not make a medical diagnosis of mental competence, a few simple questions and observations may be used to determine awareness and orientation and legal capacity of a signer before a legal document is signed and notarized. This demonstrates the use of reasonable care or a higher degree of care when the foreseeable risk is higher and the burden of taking an extra precaution is low.
Notarizations that are completed or declined should be entered in the notary journal. Occasional declines are evidence the notary does not issue an automatic stamp without checking for awareness and legal capacity.
Ask questions in a friendly, conversational manner. Thank the person for helping.
If the level of awareness or capacity is questionable, a mental health professional may be needed to test and diagnose whether the individual has adequate capacity to make legal decisions and understand what he or she is signing.
Beware of discrimination. Federal laws define a person with a disability as “Any person who has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such an impairment.“
1. Brain comparison, left normal brain vs. right brain with Alzheimer’s disease, by derivative work: Garrondo (talk) Alzheimer’s Disease Education and Referral Center, a service of the National Institute on Aging. [Public domain], via Wikimedia Commons
2. HIPAA graphic, U.S. Department of Health & Human Services (HHS), www.hhs.gov [Public domain]