Geriatric Consult

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Geriatric Consult

Date/Time:
Reason for Referral:

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...].

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Cognition:
- Cognitive domains affected include [domains].
- Short term Memory issues: [detail].
- Executive function: [detail].
- Mood: [detail].
- Hallucinations: [Yes/No and detail].
- Sleep concerns: [Yes/No and detail].

Falls/mobility:
- Dizziness with postural change: [Yes/No and detail].
- Tremor: [Yes/No].
- Falls: [Yes/No and detail].
- Change in gait: [detail].

Functional Assessment:
- Activities of daily living (ADLs): [detail].
- Instrumental activities of daily living (IADLs): [detail].
- Mobility and gait: [detail].

Social History:
- Living situation: [detail].
- Support system: [detail].
- Occupation and retirement status: [detail].
- Alcohol, tobacco, and substance use: [detail].

Other Geriatric Syndromes:
(Include this section only if at least one item applies.)
- Falls: [detail].
- Weight changes: [detail].
- Dietary intake: [detail].
- Chronic pain issues: [detail].
- Sleep issues: [detail].

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

Physical Examination:
(Hyphenated list)
- [Vital signs in one line if mentioned (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)]
- [Stated physical examination findings, one line per system. If a normal exam is mentioned, use standard phrasing (eg., Respiratory: Chest clear to auscultation bilaterally, no wheezes or crackles; Cardiac: Normal S1/S2, no murmurs, rubs or gallops; Abdomen: Soft, non-distended, non-tender.)]

Investigations:
(Hyphenated list)
- [Lab values if mentioned in one line using abbreviations]
- [Imaging if mentioned]

Assessment & Plan:
(Use medical terminology if appropriate. Do not fabricate.)
[One-sentence patient summary including age, sex, and primary diagnosis if not redundant]

#) [Assessment as a numbered item]
- [Hyphenated list with each corresponding plan item on a new line]