Today I saw Mrs. Evelyn Reed in person at the Geriatric Clinic on 1 November 2024. Mrs. Reed is a 82 years-old female seen for a comprehensive geriatric assessment.
PAST MEDICAL HISTORY:
* Hypertension, Dr. Smith
* Osteoarthritis, Dr. Jones
* Osteoporosis, Dr. Jones
* Depression, Dr. Brown
MEDICATIONS:
* Lisinopril 10mg daily
* Acetaminophen 500mg PRN
* Calcium/Vitamin D supplement
* Sertraline 50mg daily
ALLERGIES:
* NKDA
HISTORY OF PRESENT ILLNESS:
Mrs. Reed presents for a comprehensive geriatric assessment. She reports increasing difficulty with mobility and some memory concerns. She denies chest pain, shortness of breath, or falls. She is independent with all ADLs but has some difficulty with iADLs such as managing finances.
REVIEW OF SYSTEMS:
* CNS events: No recent falls or syncope.
* Cognition: Reports some memory difficulties, especially with recent events.
* Mood: Reports feeling down at times but denies significant depressive symptoms.
* Falls/Mobility: Reports some unsteadiness when walking, especially on uneven surfaces.
* Bone health: Reports history of osteoporosis.
* Hearing/Vision: Wears glasses for distance vision and uses hearing aids.
* Sleep: Reports difficulty falling asleep and staying asleep.
* Nutrition: Eating well, no significant weight changes.
* Continence: Continent of bowel and bladder.
FUNCTIONAL HISTORY
ADLs: Mrs. Reed is independent with bathing, dressing, toileting, and feeding.
iADLs: Mrs. Reed has some difficulty with managing finances and medication management.
Mrs. Reed uses a cane for ambulation.
SOCIAL HISTORY:
* Education: Completed high school.
* Employment: Retired from a secretarial position 15 years ago.
* Support/Living: Lives alone in her own home. Has a daughter who lives nearby and provides some support.
* Hobbies: Enjoys reading and gardening.
* Advanced care planning: Has a living will and a healthcare proxy.
* Substance use: Non-smoker, drinks alcohol occasionally, denies recreational drug use.
FAMILY HISTORY:
* Siblings: Sister with a history of diabetes.
* Maternal: Mother had Alzheimer's disease.
* Paternal: Father had a history of heart disease.
* Family history of dementia.
EXAMINATION:
Mrs. Reed is right-handed.
Alert and oriented to person, place, and time. Affect is appropriate. Speech is clear.
Vitals: BP 130/80, HR 72, RR 16, Temp 37.0C, sitting and standing.
General: Well-appearing elderly female.
HEENT: Pupils equal, round, and reactive to light. Hearing aids in place.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally.
Abdomen: Soft, non-tender, no masses.
Neurological: Cranial nerves II-XII intact. Strength 5/5 in all extremities. Gait is slow and unsteady.
Cognitive screening results (MoCA): 22/30
Prior cognitive testing:
MMSE 24/30, 6 months ago.
INVESTIGATIONS:
* CBC: WNL
* CMP: WNL
* TSH: WNL
* Vitamin D: 28 (L)
PHARMACY:
CVS Pharmacy
ASSESSMENT & PLAN:
1. Cognitive Impairment:
* Rationale: MoCA score of 22/30, history of memory complaints, and family history of dementia.
* Plan: Schedule a follow-up cognitive assessment in 6 months. Discussed strategies for memory improvement.
2. Mobility Issues:
* Rationale: Slow gait, reports unsteadiness.
* Plan: Refer to physical therapy for gait and balance training. Recommend home safety assessment.
3. Vitamin D Deficiency:
* Rationale: Vitamin D level of 28.
* Plan: Prescribe Vitamin D supplementation.
Plan for follow up: Follow up in 3 months.
They were invited to contact the clinic if concerns arise sooner. Thank you for the opportunity to participate in the care of your patient.
Dr. Thomas Kelly, MD, FRCPC
Geriatric Medicine and Internal Medicine
99214, 30 minutes, 10 minutes
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Today I saw [Patient Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [in person or via telehealth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) at [location] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) on [today's date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). [Patient first name] is a [age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) years-old [sex] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) seen for [reason for referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). [date of last visit statement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [accompaniment details, including who attended and relationship] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [referrer and GP details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PAST MEDICAL HISTORY:
[Past medical history items, one per line; include treating clinician for each problem when applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MEDICATIONS:
[Current medications, one per line; list vitamins/supplements together on one line] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ALLERGIES:
[Allergies and reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HISTORY OF PRESENT ILLNESS:
[HPI narrative, including information from referring clinician if provided; organize by topic; include INTERVAL HISTORY for follow-ups; exclude in-clinic cognitive testing details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
REVIEW OF SYSTEMS:
CNS events: [CNS events details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cognition: [cognition details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mood: [mood details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Falls/Mobility: [falls/mobility details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Bone health: [bone health details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hearing/Vision: [hearing/vision details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Sleep: [sleep details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Nutrition: [nutrition details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Continence: [continence and bowel habit details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
FUNCTIONAL HISTORY
ADLs: [basic ADLs description in paragraph form] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
iADLs: [instrumental ADLs description in paragraph form] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient first name] uses [type of gait aid] gait aid for ambulation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[additional home supports and services, including schedules/frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SOCIAL HISTORY:
Education: [highest level of education] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Employment: [employment history, including reason/timing of retirement if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Support/Living: [living situation, marital status, family/supports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hobbies: [hobbies and activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Advanced care planning: [advance directives / substitute decision-maker status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Substance use: [smoking, alcohol, recreational drug use summary] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
FAMILY HISTORY:
Siblings: [siblings’ health and ages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Maternal: [maternal family history details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Paternal: [paternal family history details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[statement on family history of dementia, movement disorder, or psychiatric disorder] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
EXAMINATION:
[Patient first name] is [handedness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[insight, affect, speech, and orientation/current-events summary] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Vitals: [vitals sitting and standing formatted on one line] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[additional physical examination notes performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[neurological examination findings performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[cognitive screening results (MoCA or MMSE) in standard format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Prior cognitive testing:
[prior cognitive testing details—score, date, and point losses in standard format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INVESTIGATIONS:
[labs, imaging, and other investigations; format labs without units, use standard abbreviations; mark (H)/(L); group same-date results on one line] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PHARMACY:
[Name and location of pharmacy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASSESSMENT & PLAN:
[numbered issues with brief rationale/differential and bullet-pointed plan under each] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Plan for follow up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
They were invited to contact the clinic if concerns arise sooner. Thank you for the opportunity to participate in the care of your patient.
[Clinician Name], MD, FRCPC
Geriatric Medicine and Internal Medicine
[billing code, billing time, and additional collateral time in minutes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
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