HSN - Outpatient CGA

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

<b>Comprehensive Geriatric Assessment</b>

<b>Accompanied By</b>: [Name and relationship of accompanying person]
Informed Consent For CGA Obtained: [Yes/no] [Obtained from: patient/caregiver]
Confirmed patient with 2 person-specific identifiers: [Yes/no]

<b>Referral </b>
Primary Care Practitioner: [Name]
Referral Source: [Name]
Referral Date: [Date]
NESGS Triage Priority: [Priority level]
Reason for Referral: [Reason]

Patient Expectations: [Patient’s expectations]
Caregiver Expectations: [Caregiver’s expectations]

<b>History of Presenting Problems:</b>
(hyphenated list)
- Emergency Department visits in the last year: [Yes/No]
- Hospitalizations in the last year: [Yes/No]

- [Description of presenting problems]

<b>Cognition: </b>
- [History of onset and progression of cognitive impairment]

<b>Current Symptoms:</b>
(hyphenated list)
- Decreased short term memory/Repetitiveness [Yes/No]
- Word finding difficulty [Yes/No]
- Decreased recognition of faces/people [Yes/No]
- Disoriented in new places/getting lost [Yes/No]
- Impaired executive dysfunction [Yes/No]
- Loss of purposeful movement [Yes/No]

<b>Summary of Cognitive Testing:</b>
MMSE:
- Serial Sevens: [Score out of 30], [Comments]
- WORLD Backwards: [Score out of 30], [Comments]

<b>Clock Drawing:</b>
- Score (A=abnormal/N=normal): [Score]
- Comments: [Comments]

<b>Semantic Fluency:</b>
- Total #: [Number]
- Comments: [Comments]

<b>Phonemic Fluency:</b>
- Total F: [Number]
- Total A: [Number]
- Total S: [Number]
- Total FAS: [Number]
- Comments: [Comments]

<b>MoCA:</b>
- Score out of 30: [Score]
- Comment: [Comments]

Trails A:
- Time in seconds: [Time]
- Percentage: [Percentage]
- Comments: [Comments]

Trails B:
- Time in seconds: [Time]
- Percentage: [Percentage]
- Comments: [Comments]

<b>Function</b>
(LEGEND: I=Independent; AP=Assistance due to physical impairment; AC=Assistance due to cognitive impairment; DP=Dependent due to physical impairment; DC=Dependent due to cognitive impairment; N/A=Never completed by patient in past)

<b>Activities of Daily Living:</b>
(hyphenated list)
- Transferring: [Level]
- Toileting: [Level]
- Continence: [Level]
- Eating: [Level]
- Mobility: [Level]
- Bathing: [Level]
- Dressing: [Level]
- Grooming: [Level]

<b>Instrumental Activities of Daily Living:</b>
(hyphenated list)
- Using phone: [Level]
- Grocery shopping: [Level]
- Meal preparation: [Level]
- Laundry: [Level]
- Housekeeping: [Level]

<b>Medication </b>
- Function: [Description]
- Compliance: [Description]
- Discrepancies: [Description]
- BPMH Sources: [patient/family interview, physical medication (containers/blister packs/etc.), pharmacy list, MAR (LTC/Retirement home), list from primary care or hospital, patient/family generated list]

Finances: [Description]
Transportation: [Description]
Current Hobbies: [Description]
Exercise: [Description]

What the patient continues to do well/what is the patient proud of: [Description]

<b>Mood</b>
[Past history of depression and any past treatment/institutionalizations] (in sentences)
Currently, do you often feel sad or depressed or anxious: [Yes/No]
Has the patient experienced paranoia, delusions, hallucinations, or agitation/aggression?: [Yes/No]

SIGECAPS: Summary of Mood Screens:
- Sleep: [Positive/Negative]
- Interests: [Positive/Negative]
- Guilt: [Positive/Negative]
- Energy: [Positive/Negative]
- Concentration: [Positive/Negative]
- Appetite: [Positive/Negative]
- Psychomotor slowing/Agitation: [Positive/Negative]
- Suicide: Active: [Positive/Negative], Passive: [Positive/Negative]
Total Positive SIGECAPS: [Number]

Summary of Mood Screens:
- GDS: [Score]
- SAST: [Score]
- Cornell: [Score]
- BDI: [Score]

<b>Sleep: </b>[Description]

<b>Nutrition</b>
Have you lost any weight within the last 6 months? [Yes/No]

<b>Pain:</b> [Description]

<b>Falls/Dizziness</b>
Have you had any falls? [Yes/No]

Patient Risk Factors:
(hyphenated list)
[Polypharmacy, Sedative Use, Uses a mobility aid, Weakness, MSK Conditions, Vision Impairment, Hearing Impairment, Cognitive Impairment, Risk factors in the home environment, Nutritional Concerns, Postural Hypotension, Incontinence]

<b>Continence</b>
Bladder:
Urinary Incontinence: [Yes/No]
Containment Products: [Description]
Stress: [Yes/No]
Urgency: [Yes/No]
Delay time: [Description]
Frequency: [Yes/No]
Nocturia: [Yes/No]
Hematuria: [Yes/No]
UTIs: [Yes/No]

<b>Bowel:</b>
Fecal Incontinence: [Yes/No]
Constipation: [Yes/No]
Diarrhea: [Yes/No]
GI Bleed: [Yes/No]
Bowel Routine: [Yes/No]

<b>HEENT</b>
Hearing: [Description]
Vision: [Description]
Dental: [Description]
Seizures: [Yes/No]

<b>Interventions completed by GA:</b>
(hyphenated list)
- [Interventions]

<b>Recommendations:</b>
(hyphenated list)
- [Recommendations]

<b>Physical Assessment:</b>
- Weight (kg): [Value]
- Height: [Value]
- Visual Acuity: [Value]
- TUG: [Value]
- O2 Sat: [Value]

<b>Postural Vitals:</b>
- Supine Blood Pressure: [Value]
- Supine Heart Rate: [Value]
- Immediate Standing Blood Pressure: [Value]
- Immediate Standing Heart Rate: [Value]
- 2 Minutes Standing Blood Pressure: [Value]
- 2 Minutes Standing Heart Rate: [Value]

(Do not fabricate any section or information unless explicitly mentioned in the source material)