HSN - GICS Geriatric Assessment

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<b>GICS Geriatric Assessment</b>

<b>Referral information</b>
Date of referral: [Date of referral]
Date assessed: [Date assessed]
Referring Physician: [Referring Physician]
Reason for referral: [Reason for referral]
Primary Care Provider: [Primary Care Provider]

<b>Informed consent for assessment obtained from:</b> [Name/relationship]

INFORMED CONSENT FOR ASSESSMENT The CGA with purpose, risks, limitations and benefits discussed. Client or their STM is aware they can decline or withdraw consent at any time.

<b>Patient Demographics and Contact information</b>
POA: [Name/relationship]
Personal: [Contact information]
Finances: [Contact information]

<b>Collateral Source</b><b>(s)</b><b>:</b>
(hyphenated list)
- EMR: [Specify system]
- Clinical Viewers Connecting Ontario
- Health Partner Gateway

<b>Frailty Score</b>
Baseline: [Score]
Current: [Score]

<b>Issues and Recommendations</b>
(hyphenated list)
1. Discuss with Dr. [Name] and follow-up as needed.

Noted the following from CGA:
- Cognition: [Details]
- Mood: [Details]
- Bowel/Bladder: [Details]
- Function: [Details]
- Mobility/Falls: [Details]
- Sleep: [Details]
- Social: [Details]
- Medications: [Details]
- Nutrition: [Details]
- Pain: [Details]

2. Work with the MRP, interdisciplinary care team, community services and family/caregivers to augment care and assist in the creation of a discharge plan.

<b>History of Presenting Illness</b>
[Detailed description of presenting illness, including chronology and relevant details]

<b>Past Medical History</b>
Refer to EMR for full details. Important to note but not limited to:
(hyphenated list)
- [Condition]

<b>Investigations</b>
Refer to EMR for full details. Important to note but not limited to:
(hyphenated list)
- [Investigation and result]

<b>Medications</b>
Refer to EMR for full details. Important to note but not limited to:
(hyphenated list)
- [Medication name, dose, route, frequency]

<b>Social History</b>
Living Arrangements: [Description]
Marital Status and duration: [Status, duration]
Children: [Number/names]
Place of Birth: [Location]

First Language: [Language]
Preferred Language: [Language]
Other Languages Spoken: [Languages]

Level of Education: [Education]
Occupation: [Occupation]
Leisure/hobbies/interests: [Details]
Handedness: [Left/Right/Ambidextrous]

<b>Substance Use</b>
Alcohol: [Type, amount, frequency]
Tobacco: [Type, amount, frequency]
Cannabis: [Type, amount, frequency]
Illicit drugs: [Type, amount, frequency]

<b>Sensory Aids</b>
Glasses: [Yes/No]
Hearing Aids: [Yes/No]
Dentures: [Yes/No]
Other: [Specify]

<b>Services and Supports</b>
(hyphenated list) (only list following services if mentioned)
- [NELHIN]
- [LTC choices]
- [Alzheimer’s Society]
- [Community Paramedicine Program]
- [Meal delivery service/call system]
- [NESGC Services]
- [BSO]
- [Geriatric Medicine Service]
- [Geriatric Outpatient Rehabilitation Service]
- [Geriatric Mental Health Outreach Service]

<b>Functional Status</b>

Baseline Instrumental Activities of Daily Living (IADLS)
Medication Management: [Independent/Assistance/Dependent]
Driving: [Independent/Assistance/Dependent]
Finances: [Independent/Assistance/Dependent]
Groceries: [Independent/Assistance/Dependent]
Meals: [Independent/Assistance/Dependent]
Laundry: [Independent/Assistance/Dependent]
Housekeeping: [Independent/Assistance/Dependent]
Yard work: [Independent/Assistance/Dependent]

<b>Functional Status</b>

Baseline Barthel Index
(hyphenated list)
Feeding (10, 5, 0): [Score]
Bathing (5, 0): [Score]
Grooming (5, 0): [Score]
Dressing (10, 5, 0): [Score]
Toilet use (10, 5, 0): [Score]
Stairs (10, 5, 0): [Score]
Bowels (10, 5, 0): [Score]
Bladder (10, 5, 0): [Score]
Transfers (Bed to chair and back) (15, 10, 5, 0): [Score]
Mobility (on level surfaces) (15, 10, 5, 0): [Score]
Barthel Index Score (0-100): [Score]/100

<b>Functional Status</b>

Current Barthel Index
(hyphenated list)
Feeding (10, 5, 0): [Score]
Bathing (5, 0): [Score]
Grooming (5, 0): [Score]
Dressing (10, 5, 0): [Score]
Toilet use (10, 5, 0): [Score]
Stairs (10, 5, 0): [Score]
Bowels (10, 5, 0): [Score]
Bladder (10, 5, 0): [Score]
Transfers (Bed to chair and back) (15, 10, 5, 0): [Score]
Mobility (on level surfaces) (15, 10, 5, 0): [Score]
Barthel Index Score (0-100): [Score]/100

<b>Mobility</b>
Baseline: [Description]
Stairs: [Description]
Falls: [Description]
Current: [Description]

<b>Vitals</b>
Supine: BP [Value] HR [Value] O2 [Value]
Immediate Standing: BP [Value] HR [Value] O2 [Value]
2 min standing: BP [Value] HR [Value] O2 [Value]

<b>Nutrition</b>
Baseline: [Description]
Current: [Description]

<b>Elimination</b>
Bowels:
Baseline: [Continent/Incontinent/Occasional incontinence]
Bowel routine: [Description]
Current: [Description]

Bladder:
Baseline: [Continent/Incontinent/Occasional incontinence]
Current: [Description]
Today, post-void residual was: [Value]

<b>Pain</b>
[Description]

<b>Sleep</b>
Routine: [Description]
Medication: [Description]
Change in sleep routine: [Description]
Current: [Description]

<b>Mood</b>
GDS (Geriatric Depression Screen)
Do you often feel downhearted or blue? [Yes/No]
Are you afraid something bad is going to happen to you? [Yes/No]
Do you feel that your life is empty? [Yes/No]
Do you feel happy most of the time? [Yes/No]
Are you basically satisfied with your life? [Yes/No]

<b>Cognition</b>
Baseline: [Description]
History of cognitive assessment: [Description]
Current: [Description]

CAM (Confusion Assessment Method): [Findings]

<b>Mini-cog assessment:</b>
Three-word registration: [Score]/3
Clock: [Description]
Recall: [Score]/3
Animal naming: [Description]

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