Scribe BC - Geriatric Consult

Introduction "Thank you for referring this patient to Geriatric Medicine for comprehensive geriatric assessment" Identification: [summary of patient's diagnosis and symptoms, most recent cognitive testing score, social history, and advanced care planning, frailty score, and if patient is driving] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Reason for consultation: [Reason for referral or assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) History of Present Illness: Cognition: - [Summarize cognitive domains affected including any mentioned issues with: short term memory, speech and language, visual perceptual abilities, praxis, divided attention, executive function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Describe in sentences and paragraphs) - [Short term memory problems including specific examples of forgetfulness, difficulty learning new information, or repetitive questions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Speech and language difficulties including word finding problems, naming difficulties, comprehension issues, or changes in verbal fluency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Visual or perceptual disturbances including difficulty recognizing objects, faces, or spatial orientation problems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Executive function problems including difficulty with planning, organizing, decision-making, or problem-solving tasks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Social skills changes including withdrawal from activities, loss of social judgment, or inappropriate social behavior] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Attention and concentration issues including distractibility, difficulty focusing, or problems with divided attention tasks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Current mood state including depression, anxiety, irritability, apathy, or mood swings, with description of severity, duration, and impact on daily functioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Describe in detail using sentences and paragraph format) - [Depression and anxiety screening results including specific scores from validated tools like PHQ-9, GAD-7, or GDS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Presence or absence of hallucinations including visual, auditory, or other sensory hallucinations with detailed description of content, frequency, and patient's insight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Use sentences and paragraphs.) - [Presence or absence of delusions including paranoid thoughts, fixed false beliefs, or suspicious ideation with detailed description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Use sentences and paragraphs.) - [Sleep concerns including difficulty falling asleep, staying asleep, early morning awakening, sleep quality, daytime sleepiness, or sleep medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Describe in detail using sentences and paragraphs) - [Safety concerns including wandering, getting lost, leaving stove on, medication errors, financial exploitation, or driving safety] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Describe in detail) Falls/mobility: - [Dizziness with postural changes including orthostatic symptoms, lightheadedness when standing, or blood pressure changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If present describe in detail) - [Presence or absence of tremor including rest tremor, action tremor, location, and impact on function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If present describe in detail) - [Falls history including number of falls, circumstances, injuries sustained, and contributing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If present describe in detail) - [Changes in handwriting including micrographia, illegibility, or decreased writing ability] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Changes in gait including shuffling, freezing, instability, speed changes, or use of assistive devices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If present describe in detail) - [Injuries from falls or accidents including fractures, bruises, head trauma, or emergency department visits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Advanced Care Planning: POA: [Power of Attorney status (yes/no), identity of designated person, and scope of decision-making authority including financial and healthcare decisions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Representation Agreement Section 9: [Section 9 Representation Agreement status (yes/no), identity of designated representative, and specific areas of authority for personal care and healthcare decisions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Code Status: [Current resuscitation status including full code, DNR (do not resuscitate), DNI (do not intubate), or other specific advance directives, with details of any recent discussions about goals of care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Past Medical History: - [Past medical conditions including chronic diseases, previous hospitalizations, and significant medical events with dates when available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Previous surgical procedures including type of surgery, dates, complications, and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Family History: - [Family medical history including dementia, Alzheimer's disease, Parkinson's disease, stroke, heart disease, cancer, and other hereditary conditions in parents, siblings, and children] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Medication and Allergies: - [Current medications including prescription drugs, over-the-counter medications, supplements, dosages, frequencies, and adherence issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Known allergies including drug allergies, environmental allergies, food allergies, and specific reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Social History: Social History: - Living Situation: [Current living arrangements including independent living, assisted living, family home, long-term care facility, or transitional housing, with details about safety and appropriateness of current setting] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Marital status: [Current marital status including widowed, single, married, divorced, separated, or common-law relationship, with duration and impact on social support] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Social support: [Available social support network including family caregivers, home health services, friends, neighbors, community resources, frequency of contact, and adequacy of support] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Educational status: [Highest level of education completed, literacy level, and any learning difficulties that may impact healthcare understanding] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Occupation and retirement status: [Previous occupation, retirement date, pension or financial security status, and any work-related exposures or health impacts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Substance use: - Smoking status: [Current smoking status, pack-year history, cessation attempts, and use of cessation aids] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Alcohol use: [Current alcohol consumption patterns, frequency, quantity per occasion, any history of alcohol-related problems, and impact on health and medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Other substance: [Use of recreational drugs, prescription drug misuse, cannabis, or other substances, including frequency, method of use, and impact on health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Functional History: - [Activities of daily living including bathing, dressing, toileting, transferring, continence, and feeding with level of independence or assistance needed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Describe in detail) - [Instrumental activities of daily living including cooking, cleaning, shopping, managing finances, using telephone, taking medications, and transportation with level of independence or assistance needed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Describe in detail) - [Mobility and gait assessment including walking distance, balance, use of stairs, and functional mobility] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Describe in detail) - [Use of assistive devices including walker, cane, wheelchair, grab bars, or other adaptive equipment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Driving status including current driving ability, restrictions, concerns, or cessation of driving] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Review of systems: - Weight: [Current weight, baseline weight for comparison, recent weight loss or gain with specific amounts and timeframe, possible contributing factors like appetite changes or medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Diet: [Current dietary habits including appetite level, food preferences, portion sizes, meal frequency, swallowing difficulties, nutritional concerns, and hydration status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Pain: [Current pain complaints including location, severity (0-10 scale), quality, duration, aggravating and relieving factors, current pain management strategies, and impact on daily activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Sleep: [Sleep patterns including bedtime routine, time to fall asleep, number of awakenings, total sleep time, sleep quality, daytime fatigue, napping habits, and current sleep medications or aids] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Urinary symptoms: [Urinary complaints including frequency, urgency, incontinence type and severity, nocturia, dysuria, hematuria, or urinary retention, and impact on quality of life] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Constipation: [Bowel movement patterns including frequency, consistency, straining, feeling of incomplete evacuation, associated symptoms, current treatments used, and dietary fiber intake] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Hearing Impairment: [Degree and type of hearing loss, impact on communication and social interaction, use of hearing aids or assistive devices, and need for audiological evaluation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Exam: Vitals: - Blood pressure: [Blood pressure reading (systolic/diastolic), position taken (sitting/standing), date and time of measurement, and any orthostatic changes if assessed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - O2 Saturation: [Oxygen saturation percentage, method of measurement (pulse oximetry/arterial), whether on room air or supplemental oxygen, date and time of measurement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Pulse: [Heart rate (beats per minute), rhythm (regular/irregular), quality of pulse, date and time of measurement, and any notable characteristics] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [General appearance including alertness, distress level, hygiene, and overall clinical impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Cardiovascular examination findings including heart sounds, murmurs, peripheral pulses, and signs of heart failure] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Respiratory examination findings including breath sounds, respiratory effort, and signs of respiratory distress] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Abdominal examination findings including tenderness, distention, bowel sounds, and organomegaly] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Musculoskeletal examination findings including joint mobility, muscle strength, deformities, and pain] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Neurological examination findings including mental status, cranial nerves, motor function, reflexes, coordination, and gait] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Mental status examination findings including orientation, attention, memory, language, and mood assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Investigations: - [Neuroimaging results including CT, MRI, or other brain imaging findings with dates and key results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Pertinent laboratory work including vitamin B12, TSH, calcium levels, and other relevant blood tests with values and dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Include results even if normal when discussed) Impression: - [Clinical impression summarizing the patient's condition, diagnosis, and overall geriatric assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Plan and Action: - [Management plan including specific interventions, treatments, and care recommendations] (Write in full sentences and include bullet points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Referrals to specialists or services including geriatrician, neurologist, occupational therapy, physiotherapy, or social work] (Write in full sentences and include bullet points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - [Cholinesterase inhibitor decision and management including specific medication, dosing, and patient education provided] (Write in full sentences and include bullet points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If Donepezil is started, include: "We have decided to start Donepezil. I have applied for special authority. I have prescribed 5mg p.o. daily with a goal to increase to 10mg p.o. daily in 4 weeks if tolerated. We discussed the risks/benefits of Cholinesterase inhibitors. I advised that they are not a cure nor do they stop the progression. Approximately one third of patients see some cognitive and functional benefit, one third maintain at their current state longer and one third continue to decline at the same rate. These medications have several side effects including GI upset, diarrhea, anorexia, sleep disturbances, bradycardia, falls, dizziness. They are contraindicated in patients with bradycardia or conduction abnormalities." If decision made not to start, describe the reasoning.) - [Osteoporosis management including workup and treatment decisions] (Write in full sentences and include bullet points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If treatment initiated, include: "Work up ordered today include CBC, renal function, electrolytes, Ca, Mg, P, transaminases, 25-hydroxyvitamin D, TSH, and bone mineral densiometry. Treatment initiated today: [specify oral bisphosphonate or Denosumab 60mg SC q6months, Vitamin D 1000 IU po daily]") Follow-up: - [Follow-up plan with Geriatric Medicine including timeframe and specific areas to address] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian." (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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.)