Internal Medicine — Geriatric Assessment Template
The Geriatric Assessment Template is designed for internists, geriatricians, and primary care providers conducting comprehensive evaluations for elderly patients (typically ages 65+). This template documents the multidimensional assessment including functional status, cognitive assessment, fall risk, medication review, social support, and advance care planning. The template supports appropriate billing for comprehensive geriatric assessments and includes sections for functional assessment including ADLs and IADLs, cognitive screening using standardized tools, fall risk assessment, medication review including polypharmacy assessment, social support and living situation, advance care planning discussion, physical examination including geriatric-focused assessment, assessment of geriatric syndromes, treatment recommendations, and care coordination needs. This template ensures comprehensive geriatric care, supports functional independence, identifies geriatric syndromes, and improves quality of life for elderly patients. Ideal for geriatric practices, internal medicine practices managing elderly patients, and practices providing comprehensive geriatric assessments.
Template
Visit Information
Patient age: [X] years
Visit type: Comprehensive geriatric assessment / Routine geriatric follow-up
Functional Assessment
ADLs: [Bathing, dressing, toileting, transferring, continence, feeding]
IADLs: [Shopping, cooking, cleaning, medications, finances, transportation]
Functional status: Independent / Needs assistance / Dependent
Mobility: [Walking, use of assistive devices, falls]
Cognitive Assessment
Cognitive screening: [MMSE, MoCA, or other]
Score: [If applicable]
Concerns: None / [Specify]
Memory: [Subjective and objective assessment]
Executive function: [Assessment]
Fall Risk Assessment
History of falls: None / [Frequency]
Fall risk factors: [Medications, vision, balance, etc.]
Home safety: [Assessment]
Medication Review
Total medications: [Number]
Polypharmacy: [Concern if >5-10 medications]
High-risk medications: [List if any]
Adherence: [Assessment]
Drug interactions: [If any]
Social Assessment
Living situation: [Alone, with family, facility]
Support system: [Family, friends, services]
Financial: [Concerns if any]
Transportation: [Access]
Advance Care Planning
Discussed: Yes / No
Advance directive: [Status]
Healthcare proxy: [If designated]
Code status: [If discussed]
Physical Examination
Vital signs: BP (orthostatic if indicated), HR, RR, Temp, Weight, BMI
General: [Appearance, frailty assessment]
Cardiovascular: [Complete exam]
Respiratory: [Complete exam]
Musculoskeletal: [Balance, gait, strength]
Neurological: [Cognitive, balance, gait]
Other: [As indicated]
Assessment
1) Geriatric assessment, [X] years old
- Functional status: [Assessment]
- Cognitive status: [Assessment]
- Fall risk: Low / Moderate / High
- Geriatric syndromes: [Frailty, polypharmacy, etc.]
2) [Active medical conditions: [List]]
Plan
1) Functional support: [Recommendations]
2) Cognitive: [Monitoring, referrals if needed]
3) Fall prevention: [Interventions]
4) Medication optimization: [Changes]
5) Social services: [Referrals if needed]
6) Advance care planning: [Follow-up]
7) Follow-up: [Schedule]
Patient/Family Education
Geriatric concerns discussed. Support services reviewed. Patient/family verbalized understanding.
💡 Tip: Click anywhere to edit. Changes are temporary.
Related templates
Automate Your Documentation
Use this template with OrbVoice AI medical scribe to automatically generate structured notes from patient conversations. Save 2+ hours daily while maintaining documentation quality.