Diagnostic Evaluation Note (Older Adult)

Comprehensive initial diagnostic evaluation template for geropsychology assessments of older adults. Structured for cognitive/functional status documentation, multi-informant source attribution, older-adult specific risk…

Document Type

clinical note / Diagnostic Evaluation Note

Specialties

Geropsychology

Created by Augustun

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Date of Service: [Date]

Patient: [Name or initials; age; pronouns]

Visit Type: [in-person / telehealth]

Duration: [Total time in minutes]

Location: [Clinic / Home / Facility name and unit]

Referral Source: [Name, role/title, organization]

Participants: [Patient and collateral informant(s) with relationship noted] (Indicate if collateral was interviewed separately or with patient present)

Reason for Evaluation & Information Sources

[Referral question in operational terms: diagnostic clarification / treatment planning / behavioral management / capacity evaluation] (Include patient's stated goals and caregiver/system goals when available. Note precipitating factors if urgent. Quote the patient when it adds clarity.)

Information sources: [Patient interview / collateral report with name and relationship / medical record review / prior testing / other providers consulted]
Reliability: [Factors affecting accuracy and degree of concordance between sources] (Note cognitive impairment, sensory deficits, emotional distress, language barriers if relevant)

Presenting Problem / History of Present Illness

[Chief complaint from patient, caregiver, and referrer perspectives] (Narrative format, 1–3 paragraphs. Distinguish perspectives and attribute to source. Include onset and course with timeline anchors such as hospitalizations, bereavements, or medication changes.)

[Current symptom clusters: mood, anxiety, psychosis, behavioral symptoms, sleep] [Cognitive and functional complaints: memory, language, attention, executive function, fluctuations] [Functional decline and safety events: missed medications, falls, getting lost, financial errors] [Contextual triggers: pain, sensory loss, isolation, grief, role transitions]

[Medical/medication context near symptom onset] (Note anticholinergic burden, sedatives, recent infections, anesthesia. If standardized symptom measures were administered, include instrument name, score, and interpretive range.)

Psychiatric History

Prior diagnoses: [Diagnoses with approximate dates and diagnosing clinician if known]
Prior treatments: [Outpatient therapy, psychiatry, hospitalizations; duration and response]
Suicide/self-harm history: [Attempts, self-injury, preparatory behaviors; dates and lethality]
Psychotropic medication trials: [Names, doses, duration, response, adverse effects]
Trauma history: [Relevant trauma if assessed]

(If history unavailable, state reason explicitly: "Unknown—patient unable to recall; collateral unavailable")

Medical, Neurologic & Medication History

Major medical diagnoses: [Conditions impacting cognition or mood: cardiovascular, diabetes, thyroid, stroke/TIA, head injury, Parkinsonism, sleep apnea, chronic pain]
Neurologic history: [Seizures, movement disorders, gait changes]
Sensory impairments: [Hearing, vision; whether corrected]
Recent hospitalizations/delirium: [Dates and triggers if known]
Current medications: [Medication list with adherence method] (Flag high-risk psychoactive medications: benzodiazepines, anticholinergics, opioids, Z-drugs, antipsychotics)
Allergies: [Allergies and intolerances with reactions]

Substance Use

Alcohol: [Quantity, frequency, pattern changes in late life, last use] (Note safety concerns: falls, medication interactions)
Cannabis: [Type, route, frequency; medical vs. non-medical]
Opioids: [Prescribed vs. non-prescribed; dosing]
Benzodiazepines/sedatives: [Prescribed vs. non-prescribed; dose, duration]
Tobacco: [Type, amount, duration]
Caffeine/other: [Quantity, frequency]

Cognitive Assessment

Reported Cognitive Symptoms

[Domains affected: memory, language, attention, executive function, visuospatial] [Onset and course] [Fluctuations] [Delirium red flags: acute change, inattention, altered arousal] (Clearly attribute to source: patient/collateral/record)

Brief Cognitive Testing

Instrument: [Name and version]
Score: [Total score and interpretation range] (Include education-adjusted norms if applicable)
Subdomain observations: [Strengths and weaknesses noted during tasks]
Behavioral observations: [Effort, frustration tolerance, fatigue, accommodations needed]
Limitations: [Education, language, sensory impairment, motor limitations]

Interpretation

[Restrained interpretation of screening results] (Indicate whether screening suggests possible impairment without determining etiology. State consistency with reported functional decline. Avoid over-interpretation.)

Indications for Further Evaluation

[Neuropsychological testing referral with indications and goals]
[Medical workup coordination: labs, neuroimaging, sleep evaluation]
[Monitoring plan: repeat screening interval]

Functional Status & Safety

ADLs: [Bathing / Dressing / Toileting / Transfers / Feeding] (Indicate [independent / needs cues / dependent] for each; attribute source)
IADLs: [Medications / Finances / Shopping / Cooking / Transportation / Phone-Technology / Housework] (Indicate current abilities and supports)
Mobility/falls: [Assistive devices, fall history with dates and injuries]
Driving: [Active / Retired] [Concerns or incidents] [Recommendations]
Medication management: [Pillbox / Blister packs / Caregiver administration / Automated reminders]
Financial vulnerability: [Scams, unpaid bills, unusual spending; oversight in place]
Living situation: [Residence type, cohabitants, primary caregiver, hours of assistance, backup plan]

Psychosocial Context

[Education and language preference] [Occupational and military history] [Relationship history and current supports] [Social engagement vs. isolation] [Spirituality and values] [Cultural factors affecting care] [Significant losses or grief] (Include only relevant details; attribute to source)

Family History

Dementia/neurocognitive disorders: [Relatives and age of onset if known]
Mood/psychotic disorders: [Depression, bipolar, psychosis]
Substance use disorders: [Relatives affected]
Suicide: [Family history of suicide or attempts]

(If unknown, state: "Unknown—patient unable to recall; collateral unavailable")

Mental Status Examination

Appearance/Behavior: [Grooming, hygiene, dress, cooperation]
Psychomotor: [Agitation / Retardation / Tremor / Rigidity / Gait observations]
Speech: [Rate, volume, prosody, articulation, fluency]
Mood: "[Patient's words]"
Affect: [Range, reactivity, congruence]
Thought Process: [Logical / Linear / Goal-directed / Circumstantial / Tangential]
Thought Content: [Delusions, preoccupations, themes]
Perception: [Hallucinations, illusions]
Cognition: [Orientation, attention, memory, language as observed] (Note if formally assessed above)
Insight: [Good / Fair / Limited] [Examples]
Judgment: [Good / Fair / Limited] [Examples]
Behavioral observations: [Hearing/vision accommodations, fatigue, rapport, effort]

Risk Assessment

Suicide and Self-Harm

Current ideation/plan/intent: [Presence, frequency, triggers]
Past attempts/self-harm: [Dates, methods, lethality, precipitants]
Risk factors: [Psychiatric illness, pain, losses, isolation, hopelessness, substance use, means access]
Protective factors: [Reasons for living, social supports, spirituality, treatment engagement]
Lethal means: [Firearms, medications] [Means safety counseling provided / declined]
Risk level: [Low / Moderate / High] [Rationale]
Actions taken: [Safety plan, crisis resources, supervision plan, level of care recommendation]

(If risks absent, document as explicitly assessed and denied by patient and collateral)

Violence

Ideation/plan/intent toward others: [Present / Absent]
History of violence: [Details if present]
Weapons access: [Firearms, other]
Risk level and actions: [Low / Moderate / High] [Actions taken]

Older-Adult Safety Risks

Self-neglect: [Nutrition, hygiene, living conditions]
Falls/wandering: [Risk level and mitigation]
Driving safety: [Concerns and recommendations]
Abuse/neglect/exploitation: [Suspicion level] (Document mandated reporting actions if applicable)

Assessment & Diagnostic Impressions

[Clinical formulation integrating presenting symptoms, medical/medication contributors, cognitive and functional findings, and psychosocial context] (Provide differential reasoning when relevant: depression vs. major neurocognitive disorder vs. delirium vs. medication effect vs. grief. State diagnostic certainty for each impression. Support each impression with documented data.)

[Problem 1]: [DSM-5 Diagnosis] ([ICD-10 code]) [Specifiers]

Status: [Confirmed / Provisional / Rule-out] Certainty: [Low / Moderate / High]

Rationale: [Key supporting symptoms, exam findings, test results, functional impact]

[Problem 2]: [DSM-5 Diagnosis] ([ICD-10 code]) [Specifiers]