Geriatric Care: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Geriatric SOAP notes require specialized documentation approaches that address the unique complexities of caring for older adults. Unlike standard adult documentation, geriatric notes must capture comprehensive geriatric assessments (CGA), multiple comorbidities, polypharmacy considerations, functional status, cognitive evaluation, and goals of care discussions. This guide provides detailed instructions for documenting geriatric encounters following American Geriatrics Society (AGS) guidelines and evidence-based best practices.

Unique Aspects of Geriatric Documentation

Geriatric documentation differs from standard adult notes in several critical ways:

1. Comprehensive Geriatric Assessment (CGA): A multidimensional, interdisciplinary diagnostic process to determine medical, psychological, and functional capabilities
2. Multiple Comorbidities: Older adults often have 5+ chronic conditions requiring integrated management approaches
3. Polypharmacy Considerations: Medication reconciliation, deprescribing opportunities, and Beers Criteria review are essential
4. Functional Status: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) are core documentation elements
5. Cognitive Assessment: Routine cognitive screening and monitoring for delirium are integral to geriatric care
6. Geriatric Syndromes: Falls, frailty, incontinence, sarcopenia, and failure to thrive require specific documentation
7. Goals of Care: Advance care planning and patient/family preferences guide treatment decisions
8. Caregiver Assessment: Documenting caregiver status, burden, and involvement is essential

Subjective Section (S)

In a geriatric SOAP note, the Subjective section must capture information from multiple sources including the patient, family members, and caregivers. This multi-informant approach is essential for comprehensive geriatric assessment.

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason for the visit, noting the source of information
   • Acknowledge when patient and caregiver reports differ
   • Example: "Patient states 'I feel fine.' Daughter reports increasing forgetfulness and two falls in the past month."

2. History of Present Illness:

   • Detailed description with attention to functional impact
   • Atypical presentations common in older adults (e.g., confusion instead of fever)
   • Example: "82-year-old woman with progressive memory decline over 6 months. Family notes missed medications, difficulty managing finances, and getting lost while driving familiar routes."

3. Functional Status - Activities of Daily Living (ADLs):

   • Bathing, dressing, toileting, transferring, continence, feeding
   • Document level of independence for each
   • Example: "ADLs: Independent with feeding. Requires standby assist for bathing and dressing due to balance concerns. Continent of bowel, occasional urinary urgency incontinence."

4. Functional Status - Instrumental Activities of Daily Living (IADLs):

   • Managing finances, medications, transportation, shopping, meal preparation, housekeeping, phone use
   • Example: "IADLs: No longer managing finances independently (daughter took over 3 months ago). Difficulty with medication management - uses pill box filled weekly by daughter. Stopped driving 2 months ago after getting lost."

5. Falls History:

   • Number, circumstances, injuries, fear of falling
   • Environmental factors and near-falls
   • Example: "Two falls in past 3 months. First fall occurred getting up from toilet at night, no injury. Second fall was tripping over rug, resulting in right hip pain. Reports fear of falling limiting activities."

6. Cognitive Concerns:

   • Memory, orientation, judgment, behavior changes
   • Onset, progression, and functional impact
   • Example: "Family reports progressive short-term memory decline over 1 year. Patient forgets recent conversations, repeats questions. Word-finding difficulties noted. Still recognizes family members."

7. Mood and Affect:

   • Depression and anxiety screening
   • Sleep disturbances, appetite changes
   • Example: "PHQ-2 positive. Reports decreased interest in activities, poor sleep, reduced appetite with 5 lb weight loss over 3 months."

8. Medication Review:

   • Complete medication list including OTC, supplements, herbals
   • Adherence assessment and barriers
   • Example: "Taking 12 medications. Brings all bottles - notes difficulty opening child-proof caps. Reports skipping blood pressure medication due to frequent urination. Uses ginkgo biloba for memory."

9. Nutritional Status:

   • Appetite, weight changes, diet quality
   • Swallowing difficulties, dental issues
   • Example: "Reports decreased appetite. Unintentional weight loss of 8 lbs over 6 months. Difficulty chewing meats due to ill-fitting dentures. Lives alone and relies on frozen meals."

10. Social Support and Living Situation:

    • Current living arrangement, support system
    • Caregiver availability and concerns
    • Example: "Lives alone in two-story home. Daughter visits 3x/week, manages medications and groceries. No home health services. Bedroom upstairs. Concerned about ability to remain independent."

11. Advance Care Planning:

    • Existing documents (healthcare proxy, living will, POLST/MOLST)
    • Patient's values and preferences
    • Example: "Healthcare proxy: daughter Sarah (contact info in chart). Living will completed 5 years ago - desires comfort measures only if terminal. Has not discussed POLST. States 'I don't want to be a burden.'"

12. Caregiver Input:

    • Caregiver observations and concerns
    • Caregiver burden assessment
    • Example: "Daughter (primary caregiver) expresses concern about mother's safety living alone. Reports caregiver stress - working full-time and managing mother's care. Zarit Caregiver Burden Scale: 45 (moderate burden)."

Example Subjective Section for Geriatric Care

Objective Section (O)

The Objective section in geriatric care must include comprehensive physical examination with attention to geriatric-specific assessments including cognitive screening, functional assessment, gait and balance evaluation, and nutritional status.

Objective Section (O) Components

1. Vital Signs:

   • Include orthostatic blood pressures (supine, sitting, standing)
   • Document weight with comparison to prior visits
   • Example: "BP supine 142/78, sitting 138/76, standing 118/70 (orthostatic drop), HR 68-84, Weight 132 lbs (down from 140 lbs 6 months ago)"

2. General Appearance:

   • Nutritional status, hygiene, dress appropriateness
   • Affect and engagement
   • Example: "Thin, elderly woman appearing older than stated age. Mild psychomotor slowing. Clothing seasonally appropriate but mismatched."

3. Cognitive Screening:

   • Standardized assessment tool (MMSE, MoCA, Mini-Cog)
   • Document specific deficits
   • Example: "MoCA: 18/30. Deficits in: delayed recall (0/5), visuospatial/executive (2/5), attention (4/6). Orientation 5/6 (missed date)."

4. Delirium Assessment:

   • CAM (Confusion Assessment Method) or other validated tool
   • Particularly important for acute changes
   • Example: "CAM negative. No acute change from baseline. No inattention, disorganized thinking, or altered level of consciousness."

5. Mood Assessment:

   • Geriatric Depression Scale (GDS) or PHQ-9
   • Example: "GDS-15: 8/15 (suggestive of depression). Endorsed: feeling life is empty, dropped activities, feeling helpless."

6. Gait and Balance Assessment:

   • Timed Up and Go (TUG) test
   • Get Up and Go observation
   • Romberg, tandem gait, chair stand test
   • Example: "TUG: 18 seconds (elevated fall risk). Uses furniture for support. Wide-based gait, reduced arm swing. Unable to tandem walk. 30-second chair stand: 6 (below normal for age)."

7. Functional Mobility:

   • Transfers, ambulation, stair climbing
   • Assistive device use
   • Example: "Ambulates without device but unsteady. Requires one handrail for stairs. Transfers from chair with pushoff using arms."

8. Sensory Assessment:

   • Vision and hearing screening
   • Example: "Whisper test: Unable to hear at 2 feet bilaterally (suggests hearing impairment). Wears glasses - able to read 14pt font with correction."

9. Nutritional Assessment:

   • BMI, weight trend, muscle mass
   • Oral examination (dentition, swallowing)
   • Example: "BMI: 21.5 (mildly underweight). Muscle wasting noted in temporalis and interosseous muscles. MNA-SF: 8/14 (at risk for malnutrition). Dentures ill-fitting."

10. Skin Integrity:

    • Pressure injury risk (Braden scale)
    • Skin tears, wounds, bruising
    • Example: "Braden Scale: 18 (mild risk). Thin, fragile skin. Multiple ecchymoses on forearms bilaterally (senile purpura). No pressure injuries."

11. Physical Examination:

    • Comprehensive systems-based examination
    • Particular attention to cardiovascular, neurological, and musculoskeletal findings
    • Example: See full template below

Geriatric Assessment Tools Quick Reference

Example Objective Section for Geriatric Care

Assessment Section (A)

The Assessment synthesizes findings with attention to geriatric syndromes, frailty status, prognostic considerations, and care complexity.

Assessment Section (A) Components

1. Primary Diagnoses with ICD-10 Codes:

   • List all active diagnoses being addressed
   • Include geriatric syndromes
   • Example: "Major neurocognitive disorder, likely Alzheimer type (F02.81)"

2. Geriatric Syndromes Identified:

   • Frailty, falls, cognitive impairment, incontinence, polypharmacy, malnutrition
   • Document severity and impact
   • Example: "Frailty syndrome (Clinical Frailty Scale 5/9, FRAIL score 3/5)"

3. Functional Assessment Summary:

   • Overall functional status and trajectory
   • Example: "Moderate functional impairment with dependence in 3/6 IADLs. Declining trajectory over past 6 months."

4. Polypharmacy Assessment:

   • Number of medications
   • Beers Criteria review
   • Drug interactions identified
   • Example: "Polypharmacy with 12 medications. Two Beers Criteria medications identified (diphenhydramine, omeprazole >8 weeks). Potential interaction: omeprazole with donepezil (reduced absorption)."

5. Fall Risk Assessment:

   • Risk level based on assessment tools and history
   • Modifiable risk factors identified
   • Example: "HIGH fall risk: TUG 18 sec, 2 falls in 3 months, orthostatic hypotension, polypharmacy, environmental hazards, nocturia."

6. Prognostic Assessment:

   • Consider frailty, functional trajectory, comorbidity burden
   • Use prognostic tools when appropriate (ePrognosis, mortality indices)
   • Example: "Based on functional decline, frailty (CFS 5), and comorbidity burden, estimated 4-year mortality risk is 50% per Lee Mortality Index."

7. Goals of Care Alignment:

   • Patient's stated goals
   • Current treatment alignment with goals
   • Example: "Patient goals: maximize independence, remain at home, avoid hospitalization. Current care plan aligned with goals."

8. Caregiver Assessment Summary:

   • Caregiver capacity and burden
   • Example: "Primary caregiver (daughter) showing signs of burnout with moderate burden. At risk for caregiver fatigue."

Example Assessment Section for Geriatric Care

Plan Section (P)

The Plan section must address multiple concurrent issues with attention to deprescribing, care coordination, advance care planning, and caregiver support.

Plan Section (P) Components

1. Deprescribing Recommendations:

   • Identify medications to stop, reduce, or substitute
   • Beers Criteria medications
   • Therapeutic duplications
   • Example: "Discontinue diphenhydramine (Beers Criteria, anticholinergic burden). Taper HCTZ to reduce orthostatic hypotension."

2. Medication Optimization:

   • Start/adjust medications as indicated
   • Consider simplified regimens
   • Example: "Consolidate twice daily medications to once daily where possible to improve adherence."

3. Care Coordination:

   • Referrals to specialists and services
   • Communication with other providers
   • Example: "Refer to geriatric psychiatry for depression management. Coordinate with neurology regarding dementia progression."

4. Fall Prevention Plan:

   • Home safety modifications
   • Physical therapy referral
   • Medication adjustments
   • Example: "Refer to PT for balance training and home safety evaluation. Remove scatter rugs. Install grab bars. Night light for bathroom."

5. Advance Care Planning:

   • POLST/MOLST completion
   • Goals of care discussion
   • Documentation updates
   • Example: "Discussed prognosis and goals. Will complete POLST based on patient's wishes for comfort-focused care. Fax to hospital."

6. Caregiver Support:

   • Respite care referral
   • Caregiver resources
   • Example: "Referred daughter to Caregiver Support Program. Discussed respite care options. Provided Alzheimer's Association contact."

7. Social Services:

   • Home health, adult day programs
   • Transportation resources
   • Safety planning
   • Example: "Refer to Area Agency on Aging for home safety evaluation. Consider adult day program for socialization and caregiver respite."

8. Follow-Up:

   • Interval and purpose
   • Monitoring parameters
   • Example: "Follow-up in 4 weeks to reassess orthostatic BP after medication adjustment, monitor weight, reassess depression."

Example Plan Section for Geriatric Care

AI-Assisted Documentation for Geriatric Care

AI scribes and ambient clinical intelligence are particularly valuable in geriatric care where visits are complex and involve multiple informants. According to AMA research, 66% of healthcare providers now use AI tools, with documentation being the most common application.

How AI Helps Geriatric Documentation

• Multi-source capture: Documents information from patient, family, and caregivers
• Complex medication reconciliation: Captures extensive medication discussions
• Functional assessment documentation: Records ADL/IADL discussions naturally
• Goals of care conversations: Documents nuanced advance care planning discussions
• Efficiency in complex visits: Reduces documentation burden for 60+ minute visits

Geriatric-Specific AI Considerations

What AI captures well:

• Caregiver concerns and observations
• Medication adherence discussions
• Goals of care conversations
• Social history and living situation details
• Review of systems from multiple sources

What requires careful review:

• Cognitive screening scores (verify exact numbers)
• Functional assessment details (ADLs/IADLs)
• Medication names, doses, and changes (especially deprescribing)
• Which family member provided specific information
• Advance directive specifics
• Falls details (circumstances, injuries)

Tips for Using AI with Geriatric Documentation

1. Identify speakers: "Daughter reports..." vs. "Patient states..."
2. Verbalize assessment scores: "The MoCA score is 18 out of 30"
3. State medication changes clearly: "We are discontinuing diphenhydramine due to Beers Criteria"
4. Document goals discussions: "Patient is confirming she does not want CPR"
5. Clarify functional status: "She needs standby assist for bathing"

AI-Assisted Complex Medication Reconciliation

AI-Assisted Caregiver Conversation Documentation

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Geriatric Care Documentation

Telehealth has expanded access to geriatric care, particularly for homebound patients, chronic disease management, and caregiver support. Per CMS 2026 guidelines, specific documentation requirements apply. Geriatric telehealth visits often require caregiver assistance and modified assessment techniques.

Telehealth-Specific Geriatric Documentation Requirements

For virtual geriatric visits, document:

1. Visit Logistics:

   • Platform used (HIPAA-compliant)
   • Patient and provider locations
   • Consent for telehealth
   • Who is present (patient, caregiver, family)

2. Technology Assessment:

   • Patient's ability to use technology
   • Caregiver assistance with technology
   • Audio/video quality

3. Modified Assessment:

   • What could be assessed via video
   • What required caregiver assistance
   • What could not be assessed
   • Need for in-person follow-up

4. Caregiver-Assisted Examination:

   • Document caregiver's role in examination
   • Vital signs from home devices
   • Medication bottle review

5. Home Safety Observation:

   • Environmental observations via video
   • Lighting, clutter, mobility aids visible
   • Patient's functioning in home environment

Example Telehealth Geriatric Documentation

Telehealth Considerations for Geriatric Patients

Technology Barriers in Older Adults:

• Sensory impairments affecting technology use
• Cognitive impairment limiting ability to manage devices
• Unfamiliarity with video platforms
• Need for caregiver or family assistance

Documentation of Technology Assistance:

When In-Person Geriatric Visit is Needed:

Document recommendation for in-person care when:

• Orthostatic blood pressure assessment needed
• Comprehensive cognitive testing required
• Falls assessment with TUG timing needed
• Skin integrity examination necessary
• Unexplained weight loss requiring examination
• Acute change in mental status
• Caregiver or patient concerns that require hands-on evaluation
• Gait/balance assessment with physical support needed

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Geriatric Care SOAP Note Templates

Comprehensive Geriatric Assessment Template

Falls Risk Assessment Template

Related Resources

• Telehealth SOAP Notes Guide
• AI-Assisted Documentation Guide
• Nurse Practitioner SOAP Notes
• Free SOAP Note Templates
• SOAP Note Template Hub