Family Medicine Specialist Template

Retirement Home Note

A professional Family Medicine Specialist template for healthcare professionals.

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Specialty

Family Medicine Specialist

Used

12 times

Type

Note

Last edited

23/11/2025

Created by

Harpreet Arora (Harps)

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About this template

Need a clear and concise way to document patient visits in a retirement home setting? This Retirement Home Note template is designed for family medicine specialists and other clinicians working with elderly patients. It provides a structured format to capture essential information, including medical history, social context, and current concerns. This template helps you efficiently record patient assessments, and treatment plans, ensuring comprehensive and organised medical records. It's perfect for streamlining your documentation process and improving patient care. This template is designed to be used with Heidi, the AI medical scribe, to help you create your notes quickly and easily.

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Past Medical History: - Hypertension - Type 2 Diabetes - Osteoarthritis Past Surgical History: - Right hip replacement (2018) - Cataract surgery (2020) Social History: - ADLs: Independent with bathing, dressing, and toileting. - IADLs: Manages finances with assistance, prepares simple meals. Family History: - Father: History of heart disease. - Mother: History of Alzheimer's disease. DNR Status: - Full code. MOCA Score: - 24/30 Family/Ongoing Concerns: - Daughter concerned about increasing forgetfulness. Allergies: - Penicillin Medications: - Lisinopril 20mg daily - Metformin 500mg twice daily - Ibuprofen 200mg as needed for pain Subjective: - Patient presents with a chief complaint of increasing forgetfulness and difficulty with word finding. - Duration/Timing/Location/Quality/Severity/Context of complaint: Symptoms have been gradually worsening over the past 6 months. Patient reports difficulty remembering recent events and misplacing items. The quality of the forgetfulness is described as frustrating. - Factors affecting symptoms: Stress appears to exacerbate symptoms. - Progression of symptoms: Gradual worsening of memory and word-finding difficulties. - Impact on daily activities: Difficulty with managing medications and finances. - Associated symptoms: Occasional headaches. Objective: - Oriented to person, place, and time. - Mildly impaired short-term memory. - Normal gait and balance. Assessment: - Cognitive decline, likely early-stage dementia. - Rule out other causes of cognitive impairment. Plan: - Order a complete blood count (CBC), comprehensive metabolic panel (CMP), and thyroid-stimulating hormone (TSH) to rule out other causes. - Refer to a neurologist for further evaluation and management. - Discuss medication options for cognitive support. - Schedule a follow-up appointment in 4 weeks.