Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Follow-up for known dementia
Evaluation of worsening cognitive function or new behavioral symptoms
Family meeting to discuss care plan and support services
II. History of Present Illness:
Progression of cognitive symptoms since last visit (memory decline, difficulty with daily tasks, language difficulties)
New or worsening behavioral symptoms (agitation, wandering, apathy, depression)
Impact on daily functioning and independence
Concerns of caregiver(s)
III. Past Medical History:
Type of dementia (Alzheimer’s disease, vascular dementia, Lewy body dementia, etc.) – if diagnosed
Date of diagnosis
Past medical conditions (diabetes, hypertension, heart disease)
Medications (current medications, including dementia medications)
IV. Social History:
Living situation (alone, with family, assisted living)
Social support system (availability of caregiver(s))
Advance directives (living will, power of attorney)
V. Mental Status Exam:
Orientation (to person, place, time)
Attention and concentration
Memory (immediate and remote)
Language (comprehension, expression)
Executive function (planning, judgment)
Mood and affect
VI. Functional Assessment:
Activities of daily living (ADLs): bathing, dressing, eating, toileting, grooming
Instrumental activities of daily living (IADLs): managing finances, medication management, transportation, meal preparation, housework
Ability to perform daily tasks safely and independently
VII. Assessment:
Stage of dementia based on clinical presentation and cognitive function.
Progression of cognitive decline since last visit.
Impact of dementia on daily functioning and safety.
Behavioral symptoms and potential contributing factors.
Caregiver burden and support needs.
VIII. Plan:
Treatment plan focuses on managing symptoms, promoting cognitive function, and supporting independence for as long as possible. May include:
Medications: Cholinesterase inhibitors or memantine (depending on dementia type)
Non-pharmacological interventions: Cognitive stimulation therapies, behavioral interventions, physical activity programs
Caregiver support: Education on dementia management, support groups, respite services
Safety measures: Home modifications, assistive devices, wandering prevention strategies
Advance care planning discussions: Review and update advance directives as needed.
IX. Prognosis:
Discuss the progressive nature of dementia and the expected course of the disease.
Emphasize the importance of ongoing support and care planning to optimize quality of life for the patient and caregiver(s).
X. Notes:
Address any concerns from the patient or caregiver(s).
Provide resources and referrals for support services (e.g., dementia caregiver support groups, home health care services).
Document the patient’s understanding of the diagnosis and treatment plan.
XI. Resources:
Consider providing patient and caregiver education materials on dementia from reputable sources (e.g., Alzheimer’s Association, National Institute on Aging).