PCC Comprehensive Elder Exam (HIS-865)

Structure

In the upper left corner is the assessment of basic and instrumental activities of daily living or the Functional Status Assessment. This is an essential element in geriatric assessment. A decline in functional status should trigger an investigation into causes and possible interventions. The Functional Status data can also be entered into RPMS, providing valuable information to understand long term care needs of elders. There are also questions that address health habits, work status, social supports and assistive devices.

The Geriatric Review of Systems differs from the traditional review of systems in two ways. While traditional ROS is organ and disease focused, the geriatric ROS highlights the high prevalence, multifactorial geriatric syndromes (i.e. falls, incontinence, pain) and emphasizes function as well as disease finding. The last section across the top gives room for relevant medical history and allergies.

Along the right side of the form are three distinct areasAbove the top bold line are the vitals, including a current weight and weight one year ago. Unexplained weight loss is another key indicator for further investigation. Below the bottom bold line are commonly ordered lab tests. These are not indicated routinely, but should be considered as part of a comprehensive exam.Between the bold lines are health care maintenance items. Included with those items is space to note the date at which advance directives were addressed, with the expectation that this discussion, if held, will be documented in adequate detail elsewhere.

The central portion of the form allows for a targeted physical exam and the space to document details of issues addressed above.

At the bottom is an area for medication review with the estimation of creatinine clearance to facilitate proper medication dosing. On the back of the PCC are a variety of tips and sample questions to help the provider with less experience at geriatric assessment.

Prescreening the chart and noting the dates of completion of the health care maintenance items between the bold lines on the right border improves efficiency.

—Bruce Finke, M.D.