Dementia Follow-Up & Caregiver Support Note

(Use person-centered, non-stigmatizing language throughout. Clearly attribute subjective information to the patient, caregiver/informant, or chart review. If any high-salience element—function, behaviors, safety, caregiver, medications, or goals—was not assessed today, explicitly document "Not assessed today" with brief reason.)

Date: [Date of visit]

Visit Type: [follow-up / dementia care planning update]

Setting: [clinic / telehealth / home / facility]

Patient: [Patient name and identifiers]

Participants: [Patient and each caregiver/informant present with relationship]

Historian: [Independent historian(s) and reliability statement]

Reason for Visit: [1–2 line visit focus: trajectory, behaviors, safety concern, caregiver stress, medication questions]

Interval History

Source Attribution: (Mark statements by source: patient report, caregiver report, or chart review.)

[Brief narrative summary] (5–8 sentences covering: dementia diagnosis/subtype and baseline stage; changes in cognition, function, or behavior since last visit; any safety incidents; current caregiver capacity; and updates to patient/caregiver goals or values.)

Cognition & Function: [Cognitive changes and functional status] (Address relevant domains: memory, attention, language, executive function. Note BADL/IADL dependencies, mobility, falls, wandering, nutrition/swallowing, sleep as appropriate to stage.)

Behavioral Symptoms: [Type, frequency, severity, timing/triggers, impact] (Document nonpharmacologic strategies attempted and response.)

Safety: [Dangerousness concerns: wandering/exit-seeking, driving, medication safety, firearms access, financial safety] [Environmental risks: home hazards, supervision gaps] [Mitigation steps in place or needed]

Caregiver Status: [Primary caregiver, hours/tasks, capacity/willingness, strain measure if obtained, priority needs] (If caregiver absent, note plan to obtain collateral.)

Services & Supports: [Living arrangement, supervision level, services in place]

Medications: [Medication administrator and adherence] [Dementia medication tolerability] [Psychotropic indications and response] [Anticholinergic/sedative burden concerns]

Goals of Care & ACP: [Current goals of care] [Decision-making capacity statement if decisions today] [Surrogate/POA status] [Advance directive/POLST status]

Objective

• Vitals: [Relevant vitals] (Include orthostatics if syncope/falls or cholinesterase inhibitor concerns.)
• Exam: [General appearance, hydration, signs of neglect, hearing/vision aids] [Neurologic: speech/language, parkinsonism, gait/balance, focal deficits] [Mobility observation]
• Cognitive/Functional Measures: [Tool name, score, interpretation, and change from prior] (Include staging tool, BPSD measure, depression screen, or pain tool as applicable.)
• Data Reviewed: [Relevant interval labs, imaging, hospital/ED notes, medication changes]

Assessment

(Problem-oriented synthesis in descending order of clinical risk or caregiver impact. Limit each problem to 1–3 sentences. Address as relevant: dementia stage and trajectory; functional decline; BPSD with triggers; safety risks; caregiver burden; intercurrent contributors such as delirium, pain, infection, or medication effects.)

[Problem-oriented assessment]

Plan

(Organize by problem. For each action, specify responsible party and timeline as applicable.)

• Dementia/Cognition: [Medication continuation/adjustment with rationale] [Nonpharmacologic engagement strategies] [Sensory optimization] [Follow-up interval]
• Function & Mobility: [OT/PT referral if indicated] [Home safety evaluation/DME] [Fall prevention plan]
• BPSD: [Target symptom and goal] [Nonpharmacologic plan first: trigger reduction, activity scheduling, sleep hygiene, caregiver communication] (If medication used: document indication reflecting severity/danger, risks/benefits discussion, start-low/go-slow regimen, monitoring plan, and deprescribing timeline.)
• Safety: [Driving status and alternatives] [Wandering prevention] [Firearm access resolution] [Medication safety] [Financial safety]
• Caregiver Support: [Education provided] [Burden interventions: respite, adult day, support group, counseling] [Crisis plan with contact numbers and thresholds for urgent evaluation]
• Resources Provided: [Tailored resources and mode of delivery]
• Coordination: [Communications with other clinicians/agencies: who, what, next steps]
• Follow-up: [Time-based return interval] [Event-based triggers: falls, wandering, aggression escalation, caregiver inability to cope, acute confusion]