Comprehensive Geriatric Note

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

TIME:  [Insert date and time]

IDENTIFICATION:  [Insert name of patient] is a [insert age in years] [insert gender] with a clinical frailty score of [#/9]. [Insert pronoun] was seen for a comprehensive geriatric assessment with concerns for [insert presenting concerns].

COLLATERAL CONTACTS:  
Consent for collateral information was obtained.  
1. [Name, phone number]  
2. [Name, phone number]  
(numeric list)

PAST MEDICAL HISTORY:  
1. [Condition]  
2. [Condition]  
(numeric list)

MEDICATIONS:  
Prescriptions are filled at [insert name and phone number of pharmacy]  
Current medications include:  
1. [Drug name, dosage, frequency]  
2. [Drug name, dosage, frequency]  
(numeric list)

Allergies:  
[Insert allergies or NKDA]

HABITS:  
Smoking: [Insert details]  
Alcohol: [Insert details]  
Cannabis and other: [Insert details]

HISTORY OF PRESENT ILLNESS:  
[Insert detailed history of present illness in detailed paragraphs]

GERIATRIC REVIEW OF SYSTEMS:  
1. Cognition: [Insert findings]  
2. Mood: [Insert findings]  
3. Falls: [Insert findings]  
4. Vision: [Insert findings]  
5. Hearing: [Insert findings]  
6. Sleep: [Insert findings]  
7. Nutrition: [Insert findings]  
8. Pain: [Insert findings]  
9. Continence: [Insert findings]  
10. Exercise tolerance: [Insert findings]  
11. Abuse/neglect: [Insert findings]

FUNCTIONAL HISTORY:  
1. ADLs: [Insert details]  
2. IADLs: [Insert details]  
3. Adaptive equipment: [Insert details]  
4. Community services: [Insert details]

SOCIAL HISTORY:  
Birth place: [Insert details]  
Education level: [Insert details]  
Occupation: [Insert details]  
Housing arrangement: [Insert details]  
Family: [Insert details]  
Attorney for personal care: [Insert details]  
Hobbies and interests: [Insert details]

EXAMINATION:  
[Insert physical exam findings]

COGNITIVE TESTING:  
[Insert cognitive testing results]

INVESTIGATIONS:  
Labs: [Insert relevant lab results]  
PFTs: [Report only FVC, FEV/FVC, DLCO]  
ECHO: [Report only EF and any valvular abnormalities]  
ECG: [Report rhythm and QTc]

GERIATRIC ISSUES AND RECOMMENDATIONS:  
In summary, [Insert summary and recommendations]