SOAP NOTE ON ELDERLY PATIENT WITH HYPERTENTION

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.

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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

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