Geriatrics SOAP Note

Patient: [Full name] | DOB/Age: [DOB / Age] | Date: [Date of visit]
Setting & Visit Type: [clinic / home visit / SNF / ALF / post-discharge / telehealth] — [new / follow-up / transition of care]
Provider: [Provider name, credentials] | Historian: [source(s)] ([reliability note]) (Do not leave blank; if multiple sources, list all; state reliability clearly or note reason for uncertainty.)

Subjective

Chief concern: [Primary concern in patient's own words when feasible] (If quoting not feasible, attribute source.)

Interval history: [Brief narrative of symptom changes, events such as falls or hospitalizations, new diagnoses, medication changes, and functional changes since last visit] (Attribute to patient, caregiver, or records with dates when available.)

Geriatric domains (5Ms) relevant today: [What Matters Most—goals, priorities, acceptable trade-offs; Mind—cognition, mood, delirium risk; Mobility—gait, falls, assistive devices; Medications—adherence, side effects, high-risk meds, simplification opportunities; Multicomplexity—symptom burden, social factors, care coordination] (Address only domains pertinent today; for others, note "not addressed" or "stable" with brief reason. Do not infer absent findings.)

Functional status: [ADLs and IADLs compared to baseline; assistance level and who reports] (Include when decline suspected or decisions depend on function; do not assume independence without explicit report.)

Safety and supports: [Home safety, driving, caregiver strain, respite needs] (Include when relevant to today's plan.)

Objective

Vitals: [Vital signs] (Include orthostatics when relevant to dizziness, falls, or BP medication changes.)
General/Functional observations: [Appearance, affect, gait, transfers, assistive device use, cueing needed]
Exam: [Pertinent physical exam findings by system] (Document only findings that inform today's decisions.)
Cognitive/Mood testing: [Tool, score, interpretation] (Include when performed.)
Medication reconciliation: [Status and method] (State whether reconciled with patient/caregiver review vs chart only; note discrepancies.)
Data reviewed: [Relevant labs, imaging, records with dates and sources] (Note discrepancies between sources.)

Assessment

[1–3 sentence clinical summary: age, key conditions, functional and cognitive baseline, today's primary issues, what matters most when pertinent]

Prioritized problems: (Order by clinical importance; include geriatric syndromes when they drive outcomes.)

• [Problem 1] — [new / stable / worsening / improved] — [key supporting evidence]
• [Problem 2] — [status] — [key supporting evidence]
• [Additional problems as needed]

Plan

(Organize by problem in same order as Assessment.)

• [Problem 1]: [Actions—medication changes, tests, referrals, therapies] (Include indication, rationale, expected benefit, risks discussed, monitoring plan, and coordination needs. For deprescribing, document rationale and taper plan.)
• [Problem 2]: [Actions as above]
• [Additional problems as needed]

Safety net: [Tailored symptoms or triggers for urgent contact or ED evaluation based on patient's risks]

Follow-up: [Timeframe] via [in-person / telehealth / home visit / facility visit]; [what will be reassessed; who is responsible for interim tasks]

(For falls, cognition, medication safety, and caregiver involvement: if not addressed, document "not assessed today" with reason. Do not infer adherence, ADL independence, or absence of falls without explicit report. Attribute outside records and note discrepancies.)