Geriatric emr templates

Download 88.5 Kb.
Date conversion20.05.2016
Size88.5 Kb.

Geriatric EMR Templates
The following are templates that can be incorporated into electronic medical record systems to assist in training medical students and residents to provide patient-centered, evidence-based care to geriatric patients. Double underlines are provided after selection items to indicate where one would add a + or –, (reported or denied, Yes or No, observed or absent) or additional information depending on the system being used or where one could expand a macro. Macros that call up additional forms, tools or checklists are indicated in blue highlighting and include a suggested macro key. The first item below is a complete Geriatric Assessment encounter note template. Templates that follow are either specific parts of the encounter note, such as histories (Family, Social, etc.) or the geriatric physical exam. Additional macros are built into these sections which bring up geriatric assessment tools. The last item is a template for the geriatric syndrome in the Assessment portion of the SOAPnote.
The following templates included below are:

  1. Geriatric Assessment SOAPnote Template

  2. Premorbid Functional Status

  3. Geriatric Review of Systems

  4. Review of Dementia Related Symptoms

  5. Geriatric Social History

  6. Geriatric Family History

  7. Geriatric Physical Exam

  8. Functional Status: IADL

  9. Functional Status: Basic Activities of Daily Living

  10. Functional Status: Advanced ADLs

  11. Get up and Go

  12. POMA

  13. Mini-Cog

  14. Mini-Mental Status Exam

  15. Confusion Assessment Measures

  16. 2 Question Mood Screen

  17. Geriatric Depression Scale

  18. Patient Health Questionnaire 9 (PHQ-9)

  19. CAGE Score

  20. Geriatric Syndromes

1. Geriatric Assessment Template for SOAP note

Macros Keys are highlighted in Blue

Goals for Assessment/Admission/Discharge:

Patient goals__. Family goals__.
Provider goals__.

Functional History:

Premorbid Function Status: GeriPreFunctS__.

Review of Systems: GeriROS__.

Review of dementia related symptoms: GeriRODRS__.

Social History: GeriSHx__

Family History: GeriFHx__.


Physical Exam; GeriPE__.




Geriatric Syndrome GeriSyn__.

Potential Medication Interactions__.


Plan for each problem:


ACTIVE MEDICATIONS: *started/date added **stopped




Follow Up:

2. Premorbid Functional Status

Key: GeriPreFunctS

Premorbid Functional Status:

Prior to the onset of current change in health status, according to the following resource:

Patient__. Family__. Chart__. MD__. Old records__. Other__.

this patient’s condition was as follows:

Incontinence__. Urine__. Fecal__.

Dementia__. Previous MMSE score__. Date__.

State of Consciousness__.

Communication: Verbal__. Written__. Primary language__..

Mobility__. Human assist__. Cane__. Walker__. Wheelchair__.

Appetite__. Sleep habits__.

Bed Mobility__. Transfer__.

Toilet__. W/o assistance__.

Bathe__. W/o assistance__.

Dress__. W/o assistance__.

Feed self__. W/o assistance__.

Groom__. W/o assistance__.

Shopping__. W/o assistance__.

Cooking__. W/o assistance__.

Laundry__. W/o assistance__.

Telephone__. W/o assistance__.

Medications__. W/o assistance__.

Housekeeping__. W/o assistance__.

Manage money__. W/o assistance__.

Driving__. W/o assistance__.

3. Geriatric Review of Systems

Key: GeriROS


Associated/Constitutional: Anorexia__. Confusion__. Falls__. Fatigue__. Fever__. Hypothermia__. Lethargy__. Malaise__. Mobility__. Weakness generalized__. Weight Gain__. Weight Loss__. .

Endocrine: Cold Intolerance__. Heat Intolerance__..

Hematologic/Lymphatic: Bleeding__. Bruising__. Ecchymosis__. Epistaxis__. Lymphadenopathy__. Petechiae__. Transfusions__. .

Allergic/Immunologic: Food Allergies__. Recent Infection__. Seasonal Allergies__. Medication Allergies__. .

ENT: Negative Head ears mouth nose and throat systems review__. Dental or Teeth Problems__. Dentures__. Drooling__. Dry Mouth__. Gingivitis__. Hearing loss__. Hoarseness__. Jaw Pain__. Oral Ulcerations__. Otalgia__. Post Nasal Drainage__. Sore Throat__. Problems Swollowing__. Taste__. Tinnitus__. .

Eyes: Blurred Vision __. Eye Pain__. Vision Impairment__. Central vision__. Peripheral vision__. Night vision___. Near vision__. .

NECK: Negative neck systems review__. Neck Limited Motion__. Neck Pain__. Neck Swelling__.

LUNGS/Respiratory: Negative lungs-respiratory systems review__. Cough__. Dyspnea__. Hemoptysis__. Orthopnea__. Wheezing__. .

HEART/Cardiovascular: Negative HEART-CARDIOVASCULAR systems review__. Chest Pain__. Palpitations__. Shortness of Breath__. .

ABD/Gastrointestinal: Negative abdominal/gastrointestinal review__. Abdomen Pain__. Constipation__. Diarrhea__. Heart Burn__. Hematemesis__. Hematochezia__. Hernia__. Melena__. Nausea__. Regurgitation__. Bowel movement changes__. Vomiting__. .

GENT/Genitourinary: Negative genital/urinary/rectal/breast systems review__. Breast Mass__. Dysuria__. Hematuria__. Hemorrhoids__. Nocturia__. Pelvic Pain__. Stool Incontinence__. Urinary Incontinence__. Urine Flow Slow__. Urine Frequency__. Urine Hesitancy__. Urine Urgency__. .

BJE/Musculoskeletal: Negative bones/joints/extremities/musculoskeletal systems review__. Arthralgia__. Back Pain__. Heel Pain__. Hip Pain__. Joint Stiffness__. Joint Swelling__. Knee Pain__. Leg Pain__. Myalgia__. .

SKIN/Integumentary: Negative skin systems review__. Skin Lesions__. Bruising__. Diaphoresis__. Dry Skin__. Edema__. Erythema__. Hair Problems__. Jaundice__. Mole Changes__. Nail Problems__. Pressure Ulcers__. Pruritus__. Rash__. Tears__. Locations__. Varicose Veins__. Other Skin Lesions__. Locations__. .

NEURO: Negative neurological systems review__. Balance__. Confusion__. Dizziness__. Headache__. Falls__. Incoordination__. Memory Loss__. Paralysis__. Paresthesias__. Seizures__. Speech Impairment__. Syncope__. Tremor__. Insomnia__. .

PSYCH: Negative psychiatric systems review__. Agitation__. Anxiety__. Depressed__. Hallucinations__. Irritability__.

4. Review of Dementia-Related Symptoms

Key: GeriRODRS

Review of Dementia-Related Symptoms

Interview caregiver.

Include severity of symptom to patient and distress that symptom causes caregiver

  1. Delusions: Does the patient believe that others are stealing from him/her or planning to harm him/her in some way__.

  2. Hallucinations: Does the patient hearing voices or does he/she talk to people who are not there__.

  3. Agitation/Aggression: Is the patient stubborn or resistive of help from others__.

  4. Depression/Dysphoria: Does the patient act as if he/she were sad or in low spirits__.

  5. Anxiety: Does the patient become upset when separated from you__. Does he/she have any other signs of nervousness such as shortness of breath, sighing, being unable to relax, or feeling excessively tense__.

  6. Elation/Euphoria: Does the patient appear to feel too good or act excessively happy__.

  7. Apathy/Indifference: Does the patient seem less interested in his/her usual activities and in the activities and plans of others__.

  8. Disinhibition: Does the patient seem to act impulsively, for example, talking to strangers as if he/she knows them, or saying things that may hurt people's feelings__.

  9. Irritability/Lability: Is the patient impatient and cranky__. Does he/she have difficulty coping with delays or waiting for planned activities__.

  10. Motor Disturbance: Does the patient engage in repetitive activities such as pacing around the house, handling buttons, wrapping string, or doing other activities repeatedly__.

  11. Nighttime behaviors: Does the patient awaken you during the night, rise too early in the morning, or take excessive naps__.

  12. Appetite: Has the patient lost or gained weight, or had a change in the type of food he/she likes__.


Key: GeriSocHx


Current living situation __.

Marital Status__.

Primary Caregiver

Self__. Spouse__. Child__. Neighbor__. Personal Homemaker__. Other__.


Others in Support Group__.

Educational level/health literacy__.





Occupation/employment History__.

Financial Status__.

Insurance Type: Medicare supplement__. Long term care insurance__. Supplemental Security Income (SSI)__. Referrer to SOCARE__.

Emergency contact on file __.

Services/Community Agencies involved in care

Home health__. Homemaker/Companion__. Hospitalization__. Nursing Home__. Counseling Services__. Senior Center__. Adult Day Care__. Meals on Wheels__. Senior Meal Site__. Support Group__. Physical therapy__. Other__.

Legal tools

Representative payee__. Conservatorship__. Trust__. POA for Health Care__. POA for Finances__. Living will__. Healthcare Proxy__. Five Wishes__. Other advanced directives__. None__.

Diet/Nutrition Status

Dietary Restrictions__.

Premorbid Functional Status: GeriPreFunctS __.

6. Geriatric Family History

Key: GeriFHx

Family History

There is a family history of:

Stroke __.

CAD/MI __.

Dementia __.

Diabetes __.

Parkinson's Disease __.

Alzheimer's disease (proven by autopsy) __.

Cholesterol (hyperlipidemia) __.

Depression __.

Alcohol Dependence __.

Psychiatric Illness (specify which psychiatric disorders) __.

Cancers __.

Abuse __.

7. Geriatric Physical Exam

Key: GeriPE

Physical Exam:

Vital Signs: Normal__. Abnormal__. Orthostatic changes__. (refer to Vital Signs Chart)

General: General appearance__. Level of consciousness__. Orientation__. Cooperation__. Nutritional status__. Hygene__. Mobility__. Assistive devices__. IV/Lines__. Catheters__. Pain level score__. Speech quality__. Mood__.

Skin: Rashes__. Lesions__. Color__. Turgor__. Scars__. Nails__. Hair__. Tattoos__.

Eyes: Visual aids__. Inspection __. Vision__. Fundi exam__. Cranial nerves 2__ 3__ 4__ and 6__.

Ears: Hearing aids__. Inspection__. Otoscopic exam__. Cerumen__. Whisper test__. Finger rub test__.

Mouth: Dentures__. Inspection__. Teeth__. Gums__. Mucosa__. Tongue__. Hydration__. Hygene__.

Head and Neck: Inspection__. Skin__. Thyroid__. JVD__. Range of motion__. Carotid bruit __. Lymph nodes__. Pharynx__.

Heart: PMI__. Thrills__. Rate__. Rhythm__, Murmur__. Gallops __. Pulses__.

Lungs: Inspection __. Percussion__. Rales__. Wheezes__. Rhonchi__.

Abdomen: Inspection__. Bowel sounds__. Percussion__. Bruits__. Tenderness__. Liver__. Spleen__. Masses__. Hernia __.

G/U Female: External inspection: Mons pubis__. Labia majora__. Labia minora__. Internal inspection: Vagina__. Cervix__.

Palpation: Uterus__. Adnexa__. Masses__. Tenderness__. Rectal exam__. Breast exam__.

G/U Male: Inspection: Penis__. Urethra__. Testes__. Scrotum__. Palpation: Penis__. Urethra__. Testes__. Scrotum__. Masses__. Tenderness__. Rectal exam__. Prostate__.


Extremities: Inspection: Amputations__. Deformities__. Color__. Edema__. Varicosities__.

Palpation: Peripheral pulses __.

Assistive devices__. Station__. Stability__. Symmetry__. Alignment__.

Motor exam: Range of motion__. Strength__. Grasp__. Tone__. Crepitus__. Defects__. Tenderness__. Masses__. Fine motor skills__.

Gait Assessment: getupngo__.

Neurologic: Oriented to Date__. Time__. Place__.

Cognition: Mental status: CAM__. minicog__. MMSE__.

CN 2-12 __. Sensory exam__. Pain__. Touch__. Proprioception__. Reflexes __.

Balance__. Romberg___. Nudge__.

Coordination__. finger to nose testing __. rapid alternating movements __. Tremors__. Abnormal movements__.

Psychiatric: Mood__. Affect__. 2qm__. PHQ9___. Judgement__. CAGE__.



Telephone Usage

Do not use at all __.

Answer the phone but do not dial __.

Dial a few well-known numbers __.

Use telephone at own initiative __.

No access to telephone __.


Unable to shop __.

Needs to be accompanied to shop __.

Shops independently for small purchases __.

Shops independently __.

Food Preparation

Need to have meals prepared and served __.

Can prepare meals but do no maintain adequate diet __.

Prepare adequate meals if ingredients are supplied __.

Plan, prepare, and serve adequate meals __.


Unable to perform any housekeeping tasks __.

Needs help with all home maintenance tasks __.

Perform light tasks(dishwashing, bed making) __.

Maintain house alone or with occasional assistance __.


No travel at all __.

Travel on public transportation if accompanied __.

Travel alone on public transportation __.

Drive self __.

Driven by friends/relatives or taxi __.


Incapable of dispensing own medications __.

Dispense own medication if prepared before in separate dosages __.

Dispense own medications without assistance __.

Take no medications/vitamins __.


Do not manage own finances __.

Manage only day-to-day purchases, need help with banking and check writing __.

Manage financial matters independently __.

9. FUNCTIONAL STATUS: Basic Activities of Daily Living

Key: ADL

Basic Activities of Daily Living

A. Toilet

Care for self at toilet completely; no incontinence__.

Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents__.

Soiling or wetting while asleep more than once a week__.

Soiling or wetting while awake more than once a week__.

No control of bowels or bladder__.

B. Feeding

Eats without assistance__.

Eats with minor assistance at meal times and/or with special preparation of food, or help in cleaning up after meals__.

Feeds self with moderate assistance and is untidy__.

Requires extensive assistance for all meals__.

Does not feed self at all and resists efforts of others to feed him or her__.

C. Dressing

Dresses, undresses, and selects clothes from own wardrobe__.

Dresses and undresses self with minor assistance__.

Needs moderate assistance in dressing and selection of clothes__.

Needs major assistance in dressing but cooperates with efforts of others to help__.

Completely unable to dress self and resists efforts of others to help__.

D. Grooming (neatness, hair, nails, hands, face, clothing)

Always neatly dressed and well-groomed without assistance__.

Grooms self adequately with occasional minor assistance, eg, with shaving__.

Needs moderate and regular assistance or supervision with grooming__.

Needs total grooming care but can remain well-groomed after help from others__.

Actively negates all efforts of others to maintain grooming__.

E. Physical Ambulation

Goes about grounds or city__.

Ambulates within residence on or about one block distant__.

Ambulates with assistance of (check one)  a) another person __. b) railing__. c) cane __. d) walker__.

e) wheelchair__. 1). Gets in and out without help__. 2). Needs help getting in and out __.

Sits unsupported in chair or wheelchair but cannot propel self without help

Bedridden more than half the time__.

F. Bathing

Bathes self (tub, shower, sponge bath) without help__.

Bathes self with help getting in and out of tub__.

Washes face and hands only but cannot bathe rest of body__.

Does not wash self but is cooperative with those who bathe him or her__.

Does not try to wash self and resists efforts to keep him or her clean__.



Advanced Activities of Daily Living

Walk up and down a flight of stairs__. Walk one-half mile__. Perform heavy work around the house__.

11. Get Up and Go Test

Key: getupngo

Completes in <14 seconds__.

Is the person steady and balanced when sitting upright __.

Is the person able to rise without assistance of the arms __.

Does the person start walking without hesitancy __.

When walking, does each foot clear the floor well __.

Is there step symmetry, with the steps equal length and regular __.

Does the person take continuous, regular steps __.

Does the person walk straight without a walking aid __.

Is the person able to sit safely and judge distance correctly __.


Is the person able to stand with the arms folded __.

When standing, is the person steady in narrow stance __.

With eyes closed, does the person remain steady __.

When nudged, does the person recover without difficulty __.

Does the person stand with heels close together __.
For a more thorough exam: POMA__.

12. Performance-Oriented Mobility Assessment (POMA)


Performance-Oriented Mobility Assessment

Balance Assessment


Instructions: Place a hard armless chair against a wall. The following maneuvers are tested __.

1. Sitting down

0 = unable without help or collapses (plops) into chair or lands off center of chair __.

1 = able and does not meet criteria for 0 or 2 __.

2 = sits in a smooth, safe motion and ends with buttocks against back of chair and thighs centered on chair __.

2. Sitting balance

0 = unable to maintain position (marked slide forward or leans forward or to side) __.

1 = leans in chair slightly or slight increased distance from buttocks to back of chair __.

2 = steady, safe, upright __.

3. Arising

0 = unable without help or loses balance or requires > three attempts __.

1 = able but requires three attempts __.

2 = able in £ two attempts __.

4. Immediate standing balance (first 5 seconds)

0 = unsteady, marked staggering, moves feet, marked trunk sway or grabs object for support __.

1 = steady but uses walker or cane or mild staggering but catches self without grabbing object __.

2 = steady without walker or cane or other support __.

Have patient stand __.

Gait Assessment:

5a. Side-by-side standing balance

0 = unable or unsteady or holds £ 3 seconds __.

1 = able but uses cane, walker, or other support or holds for 4–9 seconds __.

2 = narrow stance without support for 10 seconds __.

5b.Timing __ - __ seconds.

6. Pull test (person at maximum position attained in #5, examiner stands behind and exerts mild pull back at waist)

0 = begins to fall __.

1 = takes more than two steps back __.

2 = fewer than two steps backward and steady __.

7a. Able to stand on right leg unsupported

0 = unable or holds onto any objects or able for < 3 seconds __.

1 = able for 3 or 4 seconds __.

2 = able for 5 seconds __.

Instructions: Person stands with examiner, walks down 10-ft walkway (measured). Ask the

person to walk down walkway, turn, and walk back. The person should use customary walking

aid __.

Bare Floor: (flat, even surface)

1. Type of surface:

1 = linoleum or tile __. 2 = wood __. 3 = cement or concrete __. 4 = other __.

[not included in scoring]

2. Initiation of gait (immediately after told to “go”)

0 = any hesitancy or multiple attempts to start __.

1 = no hesitancy __.

3. Path (estimated in relation to tape measure). Observe excursion of foot closest to tape measure over middle 8 feet of course.

0 = marked deviation __.

1 = mild or moderate deviation or uses walking aid __.

2 = straight without walking aid __.

4. Missed step (trip or loss of balance)

0 = yes, and would have fallen and two or more missed steps __.

1 = yes, but appropriate attempt to recover and no more than two missed steps __.

2 = none __.

5. Turning (while walking)

0 = almost falls __.

1 = mild staggering, but catches self, uses walker or cane __.

2 = steady, without walking aid __.

6. Step over obstacles (to be assessed in a separate walk with two shoes placed on course 4 feet apart)

0 = begins to fall at any obstacle or unable or walks around any obstacle or two missed steps __.

1 = able to step over all obstacles, but some staggering and catches self or one to two missed steps __.

2 = able and steady at stepping over all four obstacles with no missed steps __.
Interpretation of Score: 25-28 = low fall risk__. 19-24 = medium fall risk__. < 19 = high fall risk__.

13. Mini-cog

Key: minicog

Clock correct__. Names 3 items__.

14. Mini Mental Status Exam


Mini Mental Status Exam

1. What is the: Year __. Season __. Date __. Day __. Month __.

2. Where are we: State __. County __. Town __. Hospital/Building __. Floor __.

3. Name 3 Objects: 1 second to say each. Then ask the patient to name all three.

Give 1 point for each correct answer.

0 __. 1 __. 2 __. 3 __.

4. Serial 7's: 1 point for each correct answer.

0__. 1 __. 2 __. 3 __. 4 __. 5 __.

5. Ask for 3 objects repeated above:

0 __. 1 __. 2 __. 3 __.

6. Hold up a pencil and a watch: Ask patient what each is; 1 point for each correct identification.

Pencil __. Watch __.

7. Successfully repeats "No ifs, ands, or buts" __.

8. Follows this 3 stage command:

"Take a paper in your right hand, fold it in half, and put it on the floor"

0 __. 1 __. 2 __. 3 __.

9. Reads and obeys the following statement: "Close your eyes" __.

10. Writes a sentence __.

11. Copies design: __.

Total Points out of 30 = __. (nl 26-30)

15. Confusion Assessment Measures

Key: CAM

Both acute onset__. and fluctuating course__. and inattention__. and either disorganized thinking__. or altered level of consciousness__.

16. 2 Question Mood Screen

Key: 2qm

During the past month,

have you often been bothered by feeling down, depressed or hopeless? __.

have you often been bothered by little interest or pleasure in doing things? __.

Scoring: if patient answers yes to one or both, continue with the GDS __.

17. Geriatric Depression Scale

Key: GDS

Geriatric Depression Scale

Choose the best answer for how you felt over the past week.

Are you basically satisfied with your life? No__.

Have you dropped many of your activities and interests? Yes__.

Do you feel that your life is empty? Yes__.

Do you often get bored? Yes__.

Are you in good spirits most of the time? NO__.

Are you afraid that something bad is going to happen to you? Yes__.

Do you feel happy most of the time? No__.

Do you often feel helpless? Yes__.

Do you prefer to stay at home, rather than going out and doing new things? Yes__.

Do you feel you have more problems with memory than most? Yes__.

Do you think it is wonderful to be alive now? No__.

Do you feel pretty worthless the way you are now? Yes__.

Do you feel full of energy? No__.

Do you feel that your situation is hopeless? Yes__.

Do you think that most people are better off than you are? Yes__.

Score 1 point for each + answer. Cut-off: normal 0–5; above 5 suggests depression.

18. Patient Health Questionnaire 9

Key: PHQ9

Patient Health Questionnaire - 9

Over the last 2 weeks, how often have you been bothered by any of the following problems?

KEY: 0 Not at all 1 Several days 2 More than half the days 3 Nearly every day
1. Little interest or pleasure in doing things. 0__. 1__. 2__. 3__.

2. Feeling down, depressed, or hopeless. 0__. 1__. 2__. 3__.

3. Trouble falling or staying asleep, or sleeping too much. 0__. 1__. 2__. 3__.

4. Feeling tired or having little energy. 0__. 1__. 2__. 3__.

5. Poor appetite or overeating. 0__. 1__. 2__. 3__.

6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down. 0__. 1__. 2__. 3__.

7. Trouble concentrating on things, such as reading the newspaper or watching television. 0__. 1__. 2__. 3__.

8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual. 0__. 1__. 2__. 3__.

9. Thoughts that you would be better off dead, or of hurting yourself in some way. 0__. 1__. 2__. 3__.
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all__. Somewhat difficult__. Very difficult___. Extremely difficult___.

Interpretation of Total Score

Total Score - Depression Severity

0–4 - None

5–9 - Mild depression

10–14 - Moderate depression

15–19 - Moderately severe depression

20–27 - Severe depression

19. CAGE


C Have you ever felt you should Cut down__.

A Does others' criticism of your drinking Annoy you__.

G Have you ever felt Guilty about drinking__.

E Have you ever had an “Eye opener” to steady your nerves or get rid of a hangover__.

Positive response to any suggests problem drinking__.

20. Geriatric Syndrome/Risks

Key: GeriSyn

Geriatric Syndrome/Risks. This patient has (+) or * is at risk for: Constipation __. Deconditioning __. Delirium __. Depression__. Dizziness__. Drug misadventure __. Falls __.

Immobility __. Incontinence __. Malnutrition __. Osteoporosis __. Pneumonia __. Pressure Ulcers __. Sleep disorders__. Syncope__. Urinary Tract Infection __.

Key References
Reuben, DB, et al. Geriatrics at Your Fingertips. 10th Edition. American Geriatric Society. New York. 2008.

Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Sixth Edition. Peter Pompei, MD, (Ed.). American Geriatric Society. New York. 2008.

Nebeker, JR, Hurdle, JF, and Bair, BD. Medical Informatics in Geriatrics. J of Gerontology. 58A(9), 2003.

Developed by Nancy B. Clark, M.Ed. and Mariana Dangiolo, MD.

The database is protected by copyright © 2016
send message

    Main page