SOAP. Adult-Geriatric Assessment

Adult-Geriatric Assessment

Cheryl A. Glass

Adult and geriatric primary care includes assessment and comprehensive review of physical health/disease states; functional and physical abilities; and cognition, sensory, behavioral health, safety, nutrition, and social needs. Tools may be self-administered, be completed by family members, or require staff assistance and/or time testing. Some assessment tools are Internet-based, with response-driven tally of scores for clinical interpretation. Other assessment tools are available for purchase for use in smartphones.

Besides a physical assessment, independence, quality of life, and safety are evaluated. When impairments are identified, additional questions for clinicians to ask/assess include: Is there an acute identifiable event or is the impairment chronic or reversible? Is the patient able to perform the task safely, slowly, with difficulty, or with some assistance, or does the patient have total dependency? History taking and observation of the patient’s affect, gait, undressing/dressing, and communication begin the assessment by the examiner.

Patient safety with medications includes asking to demonstrate their ability to read labels on prescription bottles, open containers (especially the child-resistant type), and recognize drugs.