Comprehensive Geriatric Assessment Note

Date/Time: [Date and time of encounter] | Location: [clinic / home visit] | Visit Type: [new consult] | Referring Clinician: [Referrer name and role] | Reason for Referral: [Referral question(s)] | Patient Name/Identifiers: [Name, DOB, MRN] | Accompanied By: [Names and relationships of caregivers present] | History Sources & Reliability: [Who provided history and any limitations] | Interpreter: [Language and mode if used]

Executive Summary

• [One-sentence problem representation: age, key conditions, geriatric syndromes, reason for consult]
• [Top 3–6 prioritized issues, safety and symptom drivers first]
• Function: [Baseline vs current status in one line]
• What Matters: [Primary goals and unacceptable tradeoffs]
• Living Situation/Disposition: [Current setting and anticipated needs]

Chief Concern / Reason for Consult

[Chief concern in patient/caregiver words] (Use brief direct quotes only if they add clarity.) [Specific consult questions from referrer]

History of Present Illness

[Narrative HPI in 3–10 sentences] (Explain why geriatrics is seeing the patient now. Include timeline of symptoms and functional change; triggering events such as falls, hospitalizations, medication changes, bereavement, or caregiver loss; current symptom burden; impact on function including what patient can no longer do, assistance required, and safety incidents. Integrate patient goals and priorities where relevant.)

Past Medical and Surgical History

• Active Chronic Conditions: [Conditions with geriatric relevance]
• Prior/Current Geriatric Syndromes: [Falls history, delirium, frailty, incontinence, pressure injuries, sensory loss]
• Surgeries/Procedures Affecting Function: [Those impacting mobility, swallowing, cognition, or function]
• Recent Hospitalizations/ED Visits: [Dates and indications, especially falls, delirium, exacerbations, infections, syncope]

Allergies

• [Allergen] — [Reaction type and severity] — [true allergy / intolerance / unknown]

(If unknown, state: "Allergies: unknown—will confirm with pharmacy/records.")

Medications

Current Medications

• [Medication list with dose/route/frequency, including OTCs, supplements, PRNs]
• Pharmacy(ies) used: [Pharmacy names]

Adherence & Administration

• Who manages medications: [patient / caregiver / both]
• System used: [pillbox / blister packs / dispenser / none]
• Barriers: [missed doses / affordability / confusion / swallowing issues / access / none identified]

High-Risk Medication Concerns

• [Sedatives, anticholinergics, opioids, hypoglycemics, antihypertensives contributing to orthostasis/falls, duplications—note risks and suspected contributions to current symptoms]

Medication Changes & Recommendations

• Deprescribing candidates & rationale: [Medications and reasoning]
• Changes made today: [Medication, new dose/frequency, start/stop/taper, explicit directions]
• Monitoring plan: [What to monitor, who will monitor, timeframe]

BPMH status: [complete / partial—if partial, plan to call pharmacy or bring bottles next visit]

Social History, Supports, and Environment

• Living Situation: [Residence type and with whom patient lives]
• Caregivers & Supports: [Who helps, frequency/type of help, caregiver burden concerns, backup plan]
• Social Connection: [Isolation/loneliness concerns, meaningful activities]
• Functional Resources: [Transportation, food access, finances, medication access]
• Community Services: [Meals, senior center, adult day, home health, other services]
• Home Safety: [Stairs, bathroom setup, lighting, clutter/rugs, emergency plan, phone/alert access]
• Driving Status: [drives / stopped / restricted / never drove] (Include safety concerns if applicable.)

Comprehensive Geriatric Assessment Domains

What Matters / Goals of Care

• [Patient-stated priorities—what they want to preserve or avoid]
• [Acceptable vs unacceptable tradeoffs]
• [Key life context affecting choices]

(Include one brief direct quote if it materially clarifies goals.)

Function – ADLs and IADLs

ADLs: (For each, note baseline → current status and who provides help.)

• Bathing: [independent / needs help / dependent] | Helper: [who] | Equipment: [grab bars / shower chair / none]
• Dressing: [independent / needs help / dependent] | Helper: [who]
• Toileting: [independent / needs help / dependent] | Helper: [who] | Equipment: [raised seat / commode / none]
• Transferring: [independent / needs help / dependent] | Helper: [who] | Device: [cane / walker / wheelchair / none]
• Continence: [continent / occasionally incontinent / incontinent] | Supplies: [none / pads / briefs]
• Feeding: [independent / needs help / dependent] | Diet texture: [regular / modified]

IADLs:

• Phone: [independent / needs help / unable] | Shopping: [independent / needs help / unable] | Food prep: [independent / needs help / unable]
• Housekeeping: [independent / needs help / unable] | Laundry: [independent / needs help / unable] | Transportation: [independent / needs help / unable]
• Medications: [independent / needs help / unable] — managed by [who] using [system]
• Finances: [independent / needs help / unable] — managed by [who]

(If who manages meds/finances is unavailable: "Not available today—will obtain from [source].")

Mobility and Falls Risk

• Falls (last 12 months): [Number, circumstances, injuries]
• Assistive devices: [cane / walker / wheelchair / none] — [uses consistently / uses inconsistently / prescribed but not using]
• Contributing symptoms: [dizziness / orthostasis / neuropathy / foot pain / vision issues / none]
• Footwear/home hazards: [Concerns identified]
• Fear of falling/activity restriction: [present / absent] — [description]
• Objective testing: [Test name, result, interpretation] (Include if performed, e.g., Timed Up and Go, gait speed.)

Falls risk drivers: [Synthesized contributing factors]

Cognition

• Concerns: [Patient and caregiver observations, domains affected]
• Safety implications: [cooking / meds / driving / finances / scam vulnerability]
• Prior diagnoses/testing: [Details if known]
• Standardized testing: [Tool name, score, date, interpretation] (If performed.)
• Detection statement: [Cognitive concerns present / absent based on today's assessment]
• Plan: [Further evaluation, referrals, monitoring]

(If not tested, document why and plan: "Not tested due to [time constraints / patient declined / acute illness]; will [plan].")

Mood and Behavioral Health

• Symptoms: [Depression, anhedonia, grief, anxiety, sleep/appetite links, substance use]
• Screening: [PHQ-2 / PHQ-9 / GDS] — Score: [score] — Interpretation: [result] — Next step: [action]
• Suicidality: [Assessment and escalation plan if suspected; otherwise "not indicated"]

Other Domains

(Include when clinically relevant; omit or note "Deferred—will address next visit" if not assessed.)

• Sensory: [Vision acuity, hearing, communication impact, effect on function/falls]
• Nutrition/Weight: [Weight trend, appetite, dentition, food insecurity, dysphagia symptoms]
• Continence: [Urinary/bowel symptoms, impact on falls and skin]
• Pain: [Location, severity, functional impact, current regimen]
• Sleep: [Insomnia, possible OSA, sedative use]

Advance Care Planning Status

• Health care proxy/surrogate: [Name, relationship, legal authority confirmed]
• Advance directive/POLST/MOLST: [present / absent] — Location: [where documented]
• Code status: [full code / DNR / DNI / comfort measures] (If applicable to setting.)

(If not ready to discuss: "Discussed readiness; deferred; will revisit." If unknown: "Not available today—will obtain from [source].")

Physical Examination

• General/frailty: [Appearance, level of frailty, hydration status]
• Vital signs: [BP, HR, RR, Temp, SpO2] | Orthostatics: [if indicated]
• Weight: [Current weight] | Trend: [stable / gaining / losing]
• Cardiovascular: [Pertinent findings]
• Pulmonary: [Pertinent findings]
• Neurological: [Focal findings, cognition/affect observations]
• Gait/balance: [Observed gait, assistive device use, steadiness]
• Feet: [Footwear, skin, nails, deformities, sensation]
• Skin: [Integrity, pressure injury risk or findings]

Data Reviewed

[Labs, imaging, hospital records, consultant notes reviewed with dates and relevance to today's assessment] (Omit section if none reviewed.)

Assessment and Plan

(Use a numbered problem list ordered by: 1) immediate safety risks, 2) high symptom burden, 3) conditions threatening independence, 4) goal-aligned preventive care. For each problem, explicitly link interventions to patient goals, function outcomes, or safety outcomes. Prominently include nonpharmacologic interventions.)

1. [Problem name]

Assessment: [Etiology, contributing factors, status, relevant data; differential if uncertainty exists]

• Diagnostics: [Tests ordered, who arranges, timeframe]
• Therapeutics: [Medications with explicit doses/frequencies; nonpharmacologic measures such as PT/OT, exercise, home modifications]
• Deprescribing: [Targets and rationale]
• Referrals: [Specialists, community resources, home health with purpose]
• Ownership: [Who is responsible—geriatrics / PCP / caregiver / home health]
• Monitoring & timeframe: [What to monitor, who monitors, when]
• Link to goals: [How this addresses What Matters, function, or safety]

2. [Problem name]

Assessment: [Brief synthesis]

• [Plan elements as above]

(Continue numbering for additional problems.)

Care Coordination and Follow-up

• Referrals placed: [Referrals and purpose]
• Community resources recommended: [Resources and rationale]
• Communication to PCP/referrer: [What will be shared, how, when]
• Follow-up: [Timing and modality—in-person / telehealth / home visit]
• Contingency guidance: [When to call clinic vs ED; red flags to watch for]