When conducting a comprehensive geriatric assessment, it is essential to follow a structured format to ensure all critical aspects of the patient's health are covered. This process involves detailing the patient’s medical history, cognitive abilities, functional status, and more. Below is a detailed walkthrough of how to effectively write and format this documentation, using a typical geriatric assessment as an example.

Reason for Assessment

Begin by stating the reason for the assessment. For instance, "The patient was referred for assessment due to frequent falls and memory concerns." Include any collateral history obtained, such as information from family members. This section provides context for the subsequent details.

History

Outline the patient's history, focusing on relevant details. For example, "The patient, an 82-year-old female, has experienced increasing forgetfulness and has had three falls in the past six months." This section should provide a concise background of the patient's recent health issues.

Cognition

Detail the cognitive domains affected, such as short-term memory and executive function. An example entry could be: "Short term Memory issues: The patient struggles to recall recent events and often misplaces items." Also include mood assessments and any reports of hallucinations.

Falls/Mobility

Document any issues with falls or mobility, such as dizziness or changes in gait. For instance: "Dizziness with postural change: Yes, the patient experiences dizziness when standing up quickly."

Medical History

Provide a comprehensive account of the patient's past medical history and any surgeries. An example might be: "Past medical history includes hypertension and osteoarthritis. Previous surgeries: Hip replacement in 2018."

Functional Assessment

Assess the patient's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). For example: "The patient requires assistance with bathing and dressing and struggles with managing finances and medication."

Social History

Include information about the patient’s living situation, support system, and lifestyle habits. Example: "Lives alone in a single-story home, with regular visits from her daughter and a home care nurse."

Other Geriatric Syndromes

Note any additional geriatric syndromes, such as weight changes or chronic pain issues. For instance: "Chronic pain issues: Mild joint pain due to osteoarthritis."

Physical Examination

Record the findings from a physical examination, including vital signs and system-specific observations. Example: "Vital signs: Blood pressure 140/85 mmHg, heart rate 72 bpm."

Investigations

List any investigations conducted, such as lab work and imaging results. For example: "Neuroimaging: CT scan shows mild cerebral atrophy."

Impression

Summarize the overall impression from the assessment. For example: "The patient presents with cognitive decline, likely due to early Alzheimer's disease, and recurrent falls possibly related to postural hypotension."

Plan and Recommendations

Detail the management plan, including any prescribed medications and referrals. For instance: "Management plan: Initiate fall prevention strategies and cognitive support. Referral to physiotherapy for balance training."

Follow-up

Conclude with a follow-up plan. Example: "Schedule a follow-up appointment in 6 weeks to assess medication tolerance and effectiveness."

Incorporating AI medical scribes like Notis AI Medical Scribe can significantly enhance the efficiency and accuracy of documenting comprehensive geriatric assessments. Notis utilizes advanced voice-to-text technology to transcribe patient interactions into structured SOAP notes, streamlining the documentation process.

Time Efficiency

Notis reduces documentation time by up to 80%, allowing geriatric healthcare providers to focus more on patient care. With an average saving of 2 hours per day, clinicians can dedicate more time to addressing complex geriatric issues.

Ease of Use

Operating through a familiar interface such as WhatsApp, Notis eliminates the need for additional software, ensuring a seamless transition to digital documentation.

High Accuracy

With a transcription accuracy of 99%, Notis ensures that medical notes are precise and reliable, which is crucial for effective patient charting in geriatrics.

Comprehensive Documentation

Notis provides structured SOAP notes instantly, which are essential for comprehensive geriatric assessments. This feature supports better patient documentation and management.

By leveraging AI-powered solutions like Notis, geriatricians can optimize their documentation processes, improving the overall quality of patient care and reducing administrative burdens.