HSN - Geriatric Follow-Up Assessment

Template structure

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

<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)