Geriatric Assisted Living Assessment

Reason for visit

[Specify the reason for visit]

Presenting issue

- Symptoms: [e.g., Persistent low mood, increased anxiety, difficulty sleeping] (describe the symptoms) - Duration: [e.g., Symptoms present for the past 6 months] (specify the duration of symptoms) - Impact on daily life: [e.g., Difficulty at work, problems with relationships] (detail the impact on daily life)

Past psychiatric history

- Previous diagnoses: [e.g., Generalised Anxiety Disorder, Major Depressive Disorder] (list any previous psychiatric diagnoses) - Previous treatments: [e.g., Medication history, psychotherapy] (detail any previous treatments) - Hospitalisations: [e.g., Previous psychiatric hospitalisations if applicable] (mention any hospitalizations if applicable)

Current medications

- Medication name: [e.g., Sertraline 50 mg daily] (list current medications) - Adherence: [e.g., Good adherence, occasional missed doses] (describe medication adherence) - Side effects: [e.g., Mild gastrointestinal discomfort] (mention any side effects)

Mental status examination

- Appearance: [e.g., Well-groomed, appropriate attire] (describe appearance) - Behavior: [e.g., Cooperative, engaged] (detail behavior) - Speech: [e.g., Normal rate and volume] (describe speech) - Mood: [e.g., Depressed, anxious] (detail mood) - Affect: [e.g., Congruent with mood, restricted range] (describe affect) - Thought process: [e.g., Logical, coherent] (describe thought process) - Thought content: [e.g., No delusions, no hallucinations] (detail thought content) - Cognition: [e.g., Alert, oriented to time, place, and person] (describe cognition) - Insight: [e.g., Good understanding of condition] (mention insight) - Judgment: [e.g., Appropriate for situation] (describe judgment)

Mental health

- Depression (PHQ-9): [score → severity] - Depression (PHQ-2): [score → severity] - Anxiety (GAD-7): [score → severity]

Cognition

- Dementia (FAST): Stage [X]

Function

- ECOG: [X] - PPS: [X%]

Opioid risk

[low/moderate/high]

Assessment

- Diagnosis/Working diagnosis and ICD code: [e.g., Major Depressive Disorder, Generalized Anxiety Disorder] (record diagnosis or working diagnosis) - Severity: [e.g., Moderate symptoms, significant impairment in daily functioning] (specify severity)

Treatment plan

- Medications: [e.g., Continue Sertraline 50 mg, consider dose adjustment] (detail medication plan) - Therapy: [e.g., Recommend Cognitive Behavioural Therapy (CBT), referral to a therapist] (recommend therapy options) - Lifestyle modifications: [e.g., Encourage regular physical activity, stress management techniques] (suggest lifestyle modifications) - Follow-up: [e.g., Schedule follow-up appointment in 4-6 weeks to monitor progress] (schedule follow-up)

Safety assessment

- Suicide risk: [e.g., No current suicidal ideation or plan] (assess suicide risk) - Self-harm risk: [e.g., No current self-harming behaviors] (assess self-harm risk)

Patient and family support

- Support systems: [e.g., Discussed support from family and friends, involvement in treatment] (mention support systems) - Emergency contacts: [e.g., Provided information for emergency mental health services] (provide emergency contact information)

Next steps

- Follow-up appointment: [e.g., Scheduled for [Date]] (schedule follow-up appointment) - Referrals: [e.g., Referral to a psychologist for CBT, if applicable] (detail any referrals) - Additional testing: [e.g., No additional tests required at this time] (mention additional testing if required)