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Geriatrician
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HSN - Geriatric Follow-Up Assessment
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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™
symptoms
Breathlessness: Progressive exertional breathlessness over two months
denials of symptoms
Denies: Associated symptoms: No chest pain at rest or syncope
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
medications
Current treatment: Continue established medicines pending review
plan
Investigations: Outpatient investigations arranged
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
<b><u>Geriatric Assessor Follow-up Clinic Assessment Form</u></b> <b>Informed Consent for Follow-up Assessment Obtained:</b> [Yes/No] <b>Obtained from: </b>[Name/Relationship] <b>Date</b>: [DD/MM/YYYY] <b>Confirmed patient with 2 person-specific identifier</b>s: [Identifiers] <b>Homevisit Hand Hygiene</b>: [Completed/Not completed] <b>Patient</b>: [Patient name] <b>ARl screen completed</b>: [Yes/No/N/A] <b>Collateral/Family Present: </b>[Names/Relationship] <b>Date of last consult at NESGS:</b> [Date] <b>Updates & Review of recommendations from previous visit: </b> [Summary of updates and review] <b>Patient/Family goals for today's visit: </b> [Goals] Has the patient been to the Emergency Department since this last NESGS consult? [Yes/No] Has the patient been admitted to hospital since their last NESGS consult? [Yes/No] If YES, details: [Details] <b><u>Cognition</u></b> Changes since last visit: [Description] <b>Current Symptoms: </b> (hyphenated list) - [Amnesia] (forgetful, repetitive, misplaces) - [Aphasia] (word finding difficulty, inability to express or understand) - [Agnosia] (inability to recognize people, places or things; disorientation) - [Apraxia] (loss of ability to perform activities that they are physically and willing to do) - [Altered Perception] (altered depth perception, visual distortions, altered tactile perception) - [Anosognosia] (lack of insight into deficits) - [Apathy] (inability to initiate activities or conversation usually able to participate if engaged by caregiver) - [Executive Dysfunction] (inability to multitask, plan, sequence, organize, judgement, etc.) <b><u>Mood</u></b> Changes since last visit: [Description] Has the patient experienced paranoia, delusions, hallucinations, or agitation/aggression? [Yes/No] <b>Summary of Mood Assessment</b> GDS: [Score/Comments] Cornell: [Score/Comments] Comments: [Additional comments] <b><u>Nutrition</u></b> [Assessment] <b><u>Sleep</u></b> [Assessment] <b><u>Pain</u></b> [Assessment] <b><u>Falls</u></b> [Assessment] <b><u>Continence</u></b> [Assessment] <b><u>Functional Inquiry</u></b> (hyphenated list) - Transfers: [Description] - Toileting: [Description] - Continence: [Description] - Eating: [Description] - Mobility: [Description] - Bathing: [Description] - Dressing: [Description] - Grooming: [Description] - Using the telephone: [Description] - Grocery Shopping: [Description] - Meal Preparation: [Description] - Laundry: [Description] - Housekeeping: [Description] - Medication: [Description] - Finances: [Description] - Transportation: [Description] <b><u>Caregiver Burden</u></b> [Assessment] <b><u>Medication List</u></b> Changes since last visit [Medication changes] - [Compliance] BPMH Sources: [insert source, ex. patient/family interview, physical medication, pharmacy list, MAR, List from primary care or hospital, patient/family generated list] <b><u>Physical Assessment</u></b> <b>Weight</b>: [Value/Units] <b>Supine</b>: Blood Pressure: [Value/Units] Heart Rate: [Value/Units] <b>Immediate Standing: </b> Blood Pressure: [Value/Units] Heart Rate: [Value/Units] <b>2 Minutes Standing: </b> Blood Pressure: [Value/Units] Heart Rate: [Value/Units] <b>O2 Saturation:</b> [Value/Units] <b>Comments</b>: [Additional comments] <b><u>Summary of Cognitive Assessment</u></b> <b>MMSE</b>: [Score/Comments] - <b>WORLD</b>: [Score/Comments] - <b>Serial 7</b>: [Score/Comments] <b>Clock</b>: [Score/Comments] <b>MoCA</b>: [Score/Comments] <b>Semantic Fluency</b>: [Score/Comments] <b>Trails A</b>: [Score/Comments] <b>Trails B</b>: [Score/Comments] Comments: [Additional comments] <b>Additional Notes:</b> [Free text] (Do not fabricate any section or information unless explicitly mentioned in the source material)
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DV
Dr. Daniel Visser
Geriatrician, Netherlands
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