Clinical notes
Geriatric Consult Note Template: Syndromes, Cognition, and Function
A geriatric consult note has to hold the whole person: syndromes, cognition, function, medicines, and goals of care — not just the referral question. This template follows Scribeberry's built-in Geriatric Consult, used by clinicians managing frailty, falls, and cognitive concerns in older adults.
Geriatric Consult Note Template: Syndromes, Cognition, and Function
Ready to review- Visit details pulled in
- Letter drafted from the conversation
- Your review and signature
Key takeaways
- A geriatric consult note documents syndromes (falls, frailty, delirium), measured cognition, graded function, and goals of care — not just the referral question.
- Capacity and driving opinions must show their functional evidence and reasoning in the note.
- Deprescribing decisions and their rationale belong in the medication section, not in memory.
What is a geriatric consult note?
A geriatric consult note is a written document that records a geriatric medicine assessment of an older adult: the referral question, geriatric syndromes such as falls, frailty, incontinence, and delirium, cognitive and functional assessment, advance care planning, and an impression and plan organized diagnosis by diagnosis. A geriatric consult template gives that assessment a repeatable structure, so function and goals of care are documented as deliberately as the medical problem list.
The template below matches Scribeberry's built-in Geriatric Consult, one of the most-used specialty templates in Scribeberry. Missing information is marked Not Provided rather than inferred — in geriatrics, an undocumented cognitive screen or an unreviewed medication list is exactly where harm hides.
Blank geriatric consult note template
Copy this structure into your EMR, or use it as the Geriatric Consult inside Scribeberry, where it fills in from the encounter itself.
Geriatric consult note
ID Chief Complaint (CC) History of Present Illness (HPI) Symptoms Geriatric Syndromes Functional and Cognitive Concerns and Assessments Activities of Daily Living (ADLs) Advance Care Planning Social Supports Physical Exam Past Medical History Surgical History Family History Medications Investigations Labwork Follow-up Recommendations Impression/Plan — a diagnosis followed by a plan for each diagnosis
Example 1: Falls and frailty assessment
Geriatric consult example — recurrent falls
Fictional example for illustration only. 84-year-old seen after two falls at home; family worried about memory.
ID: 84-year-old woman living alone in a two-storey house, referred for falls and possible cognitive decline. Chief complaint: 'I keep tripping, and my daughter says I forget things.' HPI: Two mechanical falls in 3 months, no loss of consciousness, no injury. Near-fall reaching for a step stool. Slower walking; uses furniture for support. Daughter reports missed bill payments and repeated questions over 6 months. Geriatric syndromes: Falls, frailty (gait speed reduced), mild urinary urgency without incontinence. No delirium. Functional and cognitive concerns: MoCA 21/30, losses in delayed recall and executive tasks. Clock drawing impaired. Depression screen negative. ADLs: independent in basic ADLs; needs help with finances, medications, and housework. Drives short distances; no incidents. Advance care planning: Goals-of-care conversation held with patient and daughter. Wishes to remain at home; substitute decision-maker is daughter. No formal advance directive; DNR discussion deferred to next visit at patient's request. Social supports: Daughter nearby, PSW twice weekly, no community services beyond that. Physical exam: BP 128/74 sitting, 104/66 standing at 1 minute. Gait cautious, shortened stride. Timed Up and Go 16 seconds. Remainder unremarkable. Past medical history: Hypertension, osteoarthritis, osteoporosis. Medications: amlodipine, hydrochlorothiazide, acetaminophen, vitamin D. Investigations: recent CBC, electrolytes, TSH normal. Labwork: B12 pending. Impression/Plan: 1) Recurrent falls with orthostatic hypotension — review antihypertensive timing, home safety assessment, physiotherapy for gait and balance. 2) Mild neurocognitive disorder — B12, further cognitive workup, driving safety discussion, follow-up MoCA in 6 months. 3) Frailty — protein intake counselling, vitamin D continued, falls-prevention program referral. Follow-up in 6 weeks or sooner if another fall.
Example 2: Post-delirium follow-up
Second example — after a hospital delirium
Fictional example for illustration only. 79-year-old seen 3 weeks after discharge following delirium during a pneumonia admission.
Chief complaint: 'He is almost himself again, but not quite.' — wife HPI: Hypoactive delirium during 9-day admission, resolved before discharge. Since home: sleeping poorly, appetite improving, occasional word-finding difficulty. No hallucinations, no fever. Walking with a cane he did not use before. Geriatric syndromes: Resolving delirium, new mobility aid, insomnia, caregiver strain (wife sleeping in next room to monitor). Functional/cognitive: MoCA 24/30 (baseline estimated 27). ADLs independent; IADLs shared with wife since discharge. Advance care planning: SDM wife; goals documented — full treatment, hospital transfer acceptable if reversible cause. Exam: BP 122/70, afebrile. Alert, attention intact on months-backwards. Gait steady with cane. Medications reconciled: discharge quetiapine 25 mg nightly flagged for taper — indication resolved. Impression/Plan: 1) Delirium resolved, monitor cognition at 3 months. 2) Deprescribe quetiapine over 2 weeks with sleep-hygiene plan. 3) Caregiver support — respite options and community resources provided. Follow-up 6 weeks; family instructed to call for recurrent confusion, fever, or reduced intake.
How to write a geriatric consult note, step by step
- Start with ID and referral question: who referred, and what decision the consult must inform.
- Take the HPI beyond the chief complaint: trajectory, baseline, and what changed, from patient and collateral sources.
- Screen the geriatric syndromes explicitly — falls, frailty, delirium, incontinence, polypharmacy, weight loss. Absence documented is as valuable as presence.
- Measure cognition and function with named tools (e.g., MoCA) and describe ADLs and IADLs concretely.
- Document advance care planning: SDM, goals, and what was deferred and why.
- Reconcile medications against the plan; deprescribing decisions belong in the note.
- Write the impression as a numbered list — diagnosis, then its plan — so the referring clinician can act on each line.
- Close with follow-up timing and explicit return precautions for family.
Geriatric consult vs general internal medicine consult
| Element | Geriatric consult | General internal medicine consult |
|---|---|---|
| Primary lens | Function, cognition, syndromes, goals | Organ-system diagnosis and management |
| Cognitive screen | Named tool and score, every time | When indicated |
| Function | ADLs/IADLs graded explicitly | Often narrative or absent |
| Medications | Full reconciliation + deprescribing plan | Current list recorded |
| Goals of care | SDM and advance care plan documented | Variable |
Who uses a geriatric consult note, and when
Geriatricians, care-of-the-elderly physicians, and primary-care teams write geriatric consult notes in memory clinics, falls services, inpatient consultation, and community frailty programs.
- Falls, frailty, and mobility assessments.
- Memory and cognitive-concern referrals.
- Post-delirium and post-hospitalization reviews.
- Medication and polypharmacy reviews in complex older adults.
- Capacity, driving, and goals-of-care consultations.
Documentation, privacy, and record-keeping in Canada
Geriatric notes carry legal weight in capacity assessments, driving determinations, and substitute-decision-making disputes. Record the cognitive instrument and score, the functional evidence behind any capacity opinion, and who provided collateral history. In Canada, capacity and guardianship law is provincial, and physicians may have mandatory reporting duties (for example, medically unfit drivers in several provinces) — the note should show the reasoning, the discussion with the patient, and any report made.
Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.
Common mistakes that weaken a geriatric consult note
- 'Memory problems' with no named cognitive test or score.
- Falls history with no orthostatic vitals, gait assessment, or medication review.
- No ADL/IADL grading — 'independent' with no detail.
- Polypharmacy listed with no deprescribing decision or rationale.
- Goals of care 'discussed' with no SDM named or content recorded.
- Collateral history used but its source never identified.
The signing checklist
Before signing: Is the reason for the encounter explicit? Are negatives that change management recorded? Does every diagnosis have a plan with an owner and a date? Are results, counselling, and follow-up documented — or only intended?
Using this template in Scribeberry
Geriatric assessments write themselves
Choose Geriatric Consult in Scribeberry and the syndromes, cognition, ADL, and goals-of-care structure fills in from the conversation — missing items flagged, not invented. Then Smart Push the note into your EMR and spend the saved time on the plan.
Frequently asked questions
What should a geriatric consult note include?
ID and referral question, HPI, explicit geriatric syndromes, cognitive and functional assessment with named tools, ADLs/IADLs, advance care planning, social supports, exam, histories, medications, investigations, follow-up recommendations, and an impression/plan with a plan for each diagnosis.
How is a geriatric consult different from a regular consult?
It adds what general consults often omit: named cognitive screening, graded function, syndrome review (falls, frailty, delirium, incontinence), medication deprescribing, and documented goals of care — the factors that determine outcomes in older adults.
Should cognitive scores go in the note?
Yes. Record the tool and score (e.g., MoCA 21/30) plus what the deficits mean functionally, so change over time is measurable at follow-up.
Can Scribeberry generate this note automatically?
Yes. The built-in Geriatric Consult template follows this exact structure and drafts it from the recorded or dictated encounter, marking missing information as Not Provided instead of inventing it.
When is a geriatric consult note legally significant?
In capacity assessments, driving reporting, and substitute-decision-making — anywhere the note records an opinion about function or cognition that others will act on.
What cognitive documentation is expected?
A named instrument with its score (for example MoCA), the domains affected, functional correlation, and a plan for interval re-testing.
References
- Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
- Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
- Personal Health Information Protection Act (PHIPA) — Government of Ontario
- Geriatrics resources and advocacy — Canadian Geriatrics Society
- Canadian Coalition for Seniors' Mental Health — CCSMH
Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.
