Description
SOAP NOTE ON GERERATRIC PATIENT= PLEASE INCLUDE THIS FOLLOWING TO ATTACHMENT THE CGA THAT IS USE FOR GERIATRIC PATIENT PLEASE DO IT ON 67 YEAR OLD MALE A CGA is used to adjust to the aging needs of the geriatric patient. CGA should include a history and physical as well as a more detailed evaluation of common geriatric complications and syndromes that can lead to increased morbidity and mortality, as well as diminished quality of life. When completing your Comprehensive Geriatric Assessment, complete a history and physical in a well lit space allowing for easy mobility. In addition to your standard history and physical the following areas should be carefully assessed using evidence based tools whenever possible: Physical Assessment Eye exam Hearing Nutritional assessment Screening (MNA) Visual inspection BMI 24 hours diet recall Immunizations Evaluate for frailty Assess for history of fall Medication Assessment Thorough medication history Identify high risk medications on the BEERS list Assess for poly pharmacy Treatment failure Medication adherence Cognitive Assessment Assess cognition using evidenced based tool, such as Mini-Cog or MMSE Memory Delirium Executive function Behavioral issues Psychological Assessment Assess for depression signs and symptoms Use an assessment scale for depression, such as the Geriatric Depression Scale or PHQ-9 Identify signs of anxiety Assess sleep pattern. May use evidenced based sleep questionnaire if patient complains of insomnia. Social Assessment Caregiver burden Economic well-being Safety of home environment Isolation Social Activities Elder abuse Advance Directives Functional Status Assess ADLs and iADLs using and evidenced based tool, such as Katz and Lawson Assess gait/mobility with an evidenced based tool, such as the Get Up and Go Test. Assess Gait speed/balance/foot care Assess ability to drive Assess fitness level