This comprehensive geriatric assessment template is a detailed documentation tool designed for geriatricians to evaluate the multifaceted needs of elderly patients. It facilitates the thorough assessment of cognitive function, medical history, and social circumstances, ensuring a holistic approach to geriatric care. Used with Heidi, the AI medical scribe for all clinicians, this template helps users to easily:
Automatically capture a holistic clinical picture of the older adult patient in real time.
Identify functional and mobility limitations through AI-powered transcriptions and documentation, making this information readily accessible for care planning.
Outline next steps efficiently as Heidi generates clear summaries of early diagnoses, medication updates, and referrals to services like physiotherapy and home care.
A geriatric assessment template is a structured tool used by healthcare providers to evaluate an older patient’s medical, functional, cognitive, and psychosocial status. It helps guide clinical decision-making by capturing key domains such as memory, mobility, medication use, daily living activities, mood, and support systems.
In this article, we’ll talk about the importance of geriatric assessment templates, discuss the key information that must be included in all elderly care assessment documentation, provide tips on how to conduct a comprehensive senior care assessment, and most importantly, share ready-to-use and AI-enabled templates for use in your daily practice.
Why are Geriatric Assessment Templates Important?
Because people all over the world are now living longer compared to previous generations, it’s estimated that in 25 years, there will be approximately 2.1 billion people aged 60 or older.
As a side effect of our aging global population, the need for efficient yet effective elderly care has never been more urgent. Geriatric assessment templates play a vital role in helping clinicians manage this growing demand by ensuring that no essential detail is missed during time-limited consultations.
To maximize their effectiveness, geriatric assessment templates must guide senior care providers in creating comprehensive documentation while maintaining flexibility to address the evolving needs of patients. These templates ensure that care remains patient-centered and adaptable, supporting both the clinical team and the patient’s preferences.
At the Jean Bishop Integrated Care Centre, Heidi helps clinicians focus on what truly matters by working seamlessly in the background. Our AI-powered medical scribe allows them to prioritize the patient experience and human connection. Watch the video to learn how Heidi empowers senior care teams to deliver patient-first healthcare, where technology enhances, rather than hinders, the clinician-patient relationship:
Key Inclusions in Geriatric Assessment Templates
Geriatric assessments go beyond routine exams by capturing a holistic view of an older patient’s medical, cognitive, and social health. This is why a well-designed geriatric assessment template ensures that clinicians can document efficiently while ensuring that no critical domains are missed. Below, we’ll discuss the most important inclusions every geriatric assessment template should cover based on frontline clinical insight:
Current Symptoms and Functional Impact
Document the older patient’s presenting complaints, frequency of falls (if applicable), pain, memory issues, and how these symptoms interfere with their daily routine.
Past Medical History and Medications
Note the older patient’s chronic conditions, past surgeries, and a full medication list with a focus on polypharmacy and side effects relevant to geriatric care.
Cognitive and Mental Health Status
Assess and document findings on the patient’s memory retention, executive function, mood, and sleep. Additionally, it’s good practice to also screen for dementia, depression, anxiety, and delirium, as these conditions can be especially detrimental in older adults.
Functional and Mobility Assessment
Document the older patient’s ability to perform Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), their use of assistive devices (if applicable), balance issues, gait abnormalities, and fall risk.
Social Environment and Caregiver Network
Note the older patient’s living situation, family involvement, available caregiver support, as well as potential safety and isolation concerns.
Financial and Psychosocial Support
Outline the patient’s access to care, insurance coverage, and any emotional or financial stressors impacting their health decisions.
Goals of Care and Advance Preferences
Lastly, explore and document patient-centered goals, their quality of life priorities, and advanced directives such as Do-Not-Resuscitate Orders (DNR) or Do-Not-Intubate Orders (DNI).
While templates help ensure that no critical information is missed, real-world implementation can still overwhelm even the most seasoned teams. Clinicians at Compass House Surgery found themselves struggling to balance administrative demands with elderly patient care, often at the expense of their own time and well-being.
“At the end of the day, you’re generally a lot more tired, yet I would stay over an hour late, going through documents, writing referrals… It was difficult to manage,” shared Ian Parsonage, nurse partner and lead advanced care practitioner at Compass. Thankfully, they discovered Heidi.
The AI-powered medical scribe not only automated their referrals and documentation, it also streamlined their clinical workflow during patient consultations. “It was life changing,” Ian shared. With Heidi, the team at Compass House Surgery reduced their administrative workload by up to 60%, enhanced their consultation quality, and improved morale across the team. “The more you use it, the more it benefits your team and patients.”
How to Conduct a Comprehensive Geriatric Assessment
While having a high-quality geriatric assessment template at hand is a good start, using it to get a comprehensive and holistic view of the older patient’s health is another challenge. Below, we’ll discuss a step-by-step breakdown of how clinicians can conduct an effective geriatric assessments using best practices:
1. Start with the reason for referral or visit
Having sufficient context means you can create a foundational understanding of the older patient’s situation, and simply asking them (or their guardian) why the assessment is being requested in the first place goes a long way.
Common reasons may include falls, memory changes, or discovered difficulty with daily activities. If the older patient is unable to articulate their symptoms, it’s best to gather additional context from caregivers or family members as they can often provide information that’s difficult to discern during the initial visit.
2. Review current symptoms and functional impact
Once you’ve determined the older patient’s chief complaint, start asking about secondary concerns from the patient, their caregiver, family members, or referring clinicians (if applicable).
Start with open-ended questions like “Can you tell me what changes you or your family have noticed recently in your health or daily routine?” Probing this way allows you to identify other potential issues to look out for in order to get a more complete picture of the older patient’s health.
3. Conduct a detailed medical and medication review
Look into the older patient’s diagnosed chronic illnesses, past hospitalizations, and surgeries, as well as their current medications for appropriateness, side effects, and potential interactions.
It’s important to note that in older adults, polypharmacy cases can significantly increase the risk of common geriatric issues such as falls, cognitive and functional decline, because aging bodies metabolize drugs differently compared to younger adults (typically under 45 years old).
4. Assess cognitive and mental health function
Perform cognitive tests such as the Montreal Cognitive Assessment (MoCA Test) or the -Mental State Examination (MSE) to get measurable data regarding the patient’s cognitive health, and further probe their memory, ability to plan, mood fluctuations, and any signs of hallucinations or confusion.
Additionally, you should also screen for depression, anxiety, and sleep disturbances to confirm or rule out their potential role in the older patient’s cognitive status. It’s important not to skip these mental health assessments even if the older patient seems to be of sound mind and function, because cognitive issues and mood disorders are often underdiagnosed, even if they heavily impact the patient’s independence.
5. Evaluate mobility and fall risk
Observe and document the patient’s gait, run balance tests, and ask about any recent falls, tremors, or episodes of dizziness. Also note their use of walking aids and conduct a basic physical exam such as checking orthostatic vitals and running a Range of Motion (ROM) test, to gain further insight into underlying contributors to instability, dizziness, and functional limitations. Remember that falls are often preventable if root causes are uncovered early.
6. Examine social, financial, and environmental support
Ask about the patient’s living arrangements, caregiver involvement, social connections, and financial concerns that may affect treatment or follow-up care. Performing this step is important since many older adults tend to underreport their struggles unless asked directly and empathetically.
7. Explore goals of care and advanced planning
Finally, you should have a conversation with the older patient to understand what they value the most about their health. At a point where they can still communicate their wishes clearly, it’s best to clarify their code status, advance directives such as whether they want to be resuscitated or intubated once it becomes medically necessary, and confirm any end-of-life wishes when appropriate. Understanding the older patient’s values guides better decision-making, especially in chronic or progressive conditions.
Geriatric Assessment Template Example
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Geriatric assessments involve capturing a wide range of medical, cognitive, and social factors, all of which demand time, accuracy, and sharp clinical judgment. Manually documenting each aspect can be time-consuming, and not to mention prone to human error.
Fortunately, an AI-powered medical scribe can now streamline the geriatric assessment documentation process, helping clinicians complete thorough evaluations without compromising efficiency and quality.
Easily Complete Geriatric Assessment Templates with Heidi
Heidi is our state-of-the-art AI medical scribe designed to help clinicians complete their geriatric assessment templates in real time. With your older patient’s permission, simply hit record and let Heidi work as you go. Here’s how Heidi helps you complete your geriatric assessment template:
Transcribe – Open Heidi on your computer or mobile device and press Start transcribing so Heidi can capture your consultation in the background. For info that you don’t want to verbalize, you can type it under context notes to be considered later.
Customize – After the session, simply select your preferred geriatric assessment template and watch as Heidi perfectly transcribes the details of your conversation and context notes in the appropriate fields and format!
Transform – Once Heidi generates your completed geriatric assessment template, you can request to generate additional documentation, including social work case formulation as needed.
Heidi complies with jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our patient safety and data security compliance.
This senior care assessment template is designed to help physiotherapists and occupational therapists evaluate a patient’s fall risk, mobility, and care needs. It helps clinicians document the elderly patient’s medical history, current medications, social history, and community-based interventions.
This elderly care assessment template helps healthcare providers create individualized care plans that support older adults with their physical, emotional, and social needs. It includes sections for patient concerns, personal preferences, care goals, planned interventions, and services required to guide person-centered care.
Who performs geriatric assessments and in what settings?
Geriatric assessments are typically conducted by physicians, nurse practitioners, geriatricians, or multidisciplinary teams that may include social workers and physical therapists. These assessments can take place in outpatient clinics, hospitals, long-term care facilities, or even during home visits which depend on the patient’s condition and care needs.
When should a comprehensive geriatric assessment be initiated?
A comprehensive geriatric assessment should be initiated when an older adult shows signs of functional decline, frequent falls, memory loss, medication-related complications, or when major care decisions such as initiating home support or considering long-term placement are being made.
How long does a geriatric assessment take and how can I make it more efficient?
A full geriatric assessment may take anywhere from 45 to 90 minutes, depending on the complexity of the case and the number of domains being evaluated. Using an AI-powered medical scribe like Heidi can significantly reduce documentation time by automatically capturing and organizing relevant clinical details even while the consultation is ongoing, freeing up healthcare providers so they can focus more on patient care and less on paperwork. To get a clear understanding of how it works, you can access our beginner-friendly Heidi guide.
