BPSD

[GP Address] [Date] Dr [Referrer Name], Re: [Patient Full Name] DOB: [DD/MM/YYYY] Thank you for referring [Patient First Name], who was reviewed at [Facility] on [Date of Review]. A Comprehensive Geriatric Assessment was performed. The issues discussed were: Issues: 1. [List the first issue related to Behavioural and Psychological Symptoms of Dementia (BPSD)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a heading.) Impression: [Document diagnosis of BPSD, severity of dementia, and likely dementia subtype] ( Write as a brief description.) Brodaty Scale: [Document the Brodaty Scale score] Behavioural profile: [Document specific behavioural symptoms observed such as agitation, aggression, disinhibition, intrusive behaviours, wandering] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a brief description.) Treatment planned: [Document medications to discontinue, adjust or start, including dosages, frequency and timing] (Write in complete sentences.) Non-Pharmacological: [Document non-pharmacological interventions recommended] ( Write as a brief description.) Relevant Referrals: [Document any referrals made for this issue] ( Write as a brief description.) 2. [List the second issue, problem or request] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a heading.) [Document impression or likely diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) [Document differential diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) [Document investigations planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) [Document treatment planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) [Document relevant referrals for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) 3.[List additional issues, problems or requests as needed, following the same format as above] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Follow the same format as previous issues.) Past Medical History [List all relevant medical conditions chronologically with dates where known] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list with each condition on a new line.) BACKGROUND AND HISTORY [Provide detailed background summary including presenting complaint, relevant history, social context, cognitive/functional changes, patient concerns, goals, and recent health events] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences, including narrative sections with patient and family quotes where available. Aim for at least 300 words of comprehensive information.) Memory Concerns [Document onset, pattern of memory decline, and family observations regarding memory issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Functional Decline [Document loss of independence in Activities of Daily Living and changes in functional abilities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Living Environment & Family Support [Document patient's living situation before admission, family structure, recent changes, and level of family involvement] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Systems Review Weight Change: [Document information about recent weight changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Falls: [Document information about falls, including frequency, circumstances and injuries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Mood: [Document information about mood, emotional state and behavioral symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Sleep: [Document information about sleep patterns and issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Pain: [Document information about pain, including location, severity and management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Mobility/Aids Used: [Document information about mobility status and assistive devices] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Bowels: [Document information about bowel function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Bladder: [Document information about bladder function and continence] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Memory: [Document information about memory function and cognitive changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Hearing: [Document information about hearing function and aids] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Vision: [Document information about vision, visual aids and visual disturbances] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medications on Initial Review [List all current medications with dosages and indications, noting recent changes, compliance issues, and adverse reactions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list.) Allergies [Document allergies and specific reactions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Suggested Medications Following Consultation [Document recommended medication changes and reasons] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Discontinue: [List medications to discontinue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Adjust: [List medications to adjust with new dosing] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Commence: [List new medications to start with dosing] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Social History Lives: [Document current living situation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Children: [Document information about children] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Grandchildren: [Document information about grandchildren] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Born in: [Document place of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Emigrated to Australia in: [Document year of emigration if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ADLs (Personal): [Document level of independence with personal activities of daily living] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ADLs (Domestic): [Document level of independence with domestic activities of daily living] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Community Engagement: [Document information about social activities and community involvement] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Services in place: [Document current support services] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Driving: [Document driving status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Falls (last 12 months): [Document fall history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Mobility Aid: [Document mobility aids used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Education: [Document educational background] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Employment History: [Document occupational history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) EPOA/Guardianship: [Document legal arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) My Aged Care: [Document aged care services status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Smoking/Alcohol: [Document substance use history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Vaccinations: [Document vaccination status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family History: [Document relevant family medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Exercise: [Document exercise habits and limitations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Physical Examination Heart Rate: [Document heart rate] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Blood Pressure: [Document blood pressure measurements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Neuro: [Document neurological examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Weight: [Document weight] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Gait: [Document gait assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Pathology [Document recent pathology results or investigations ordered] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Cognitive Assessment Tool: [Document cognitive assessment tool used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Score: [Document cognitive assessment score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Interpretation: [Document interpretation of cognitive assessment results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Comments: [Document additional observations about cognitive function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Summary [Provide a concise summary of the patient's age, diagnosis, current presentation, and treatment focus] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) Follow-up [Document planned follow-up arrangements including dates and focus of future reviews] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences with each follow-up item on a new line.) Kind regards, [Insert Practitioner name] [Insert Practitioner credentials] [Practice/Facility Name] (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 included 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.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)