Geriatric Healthcare Maintenance Report Card (GHMRC) Instructions for PCP Completion / Chart Audit

Department of Family Medicine in Fulton and Ogden. This is a random selection of 100 patients > 65 y/o enrolled in Ambulatory sites of the Department of Family Medicine in Fulton and Ogden.   Each random patient will be assigned a unique identifier which will be placed on the Geriatric Healthcare Maintenance Report Card. Preventive care guidelines recommend that all older adults be screened for: Functional Status Cognitive Status Affect Medications BMI Pain Fall Risk Visual Hearing Alcohol Screening Tobacco Screening Physical Activity Counseling Colorectal Cancer Screening Breast Cancer Screening Elderly Mistreatment Advanced Directives

This is an instruction sheet on the use of GHMRC Please review medical record as follows: Demographics Section   A. Complete this by reviewing the medical Encounter Label Initial Adult Assessment (Orange Form) Other (eclypsis)

A. Activities of Daily Living (ADLS): Functional Status   Review notes from January 1, 2007 through December 31, 2007 looking for evidence of A. Activities of Daily Living (ADLS): Self Care in Bathing (1/0) Dressing (1/0) Feeding (1/0) Toileting (1/0) Transferring (1/0) Continence (1/0) B. Instrumental Activities of Daily Living (IADLS): Ability to Use Telephone (1/0) Shopping (1/0) Food Preparation (1/0) Housekeeping (1/0) Laundry (1/0) Mode of Transportation (1/0) Responsibility for Own Medications (1/0) Ability to Handle Finances (1/0)

Cognitive Status   A. Evidence of Completion of Cognitive Status: MMSE Mini cog Recall Clock Drawing Test Laboratory – please see chart or eclypsis Affect – please see attached PHQ 15 Medications A. Polypharmacy: Total number of medications patient is taking; B .Classification of Medications Considered Inappropriate: please refer to GHMRC BMI – Evidence of documentation and value Pain – Evidence of documentation of pain assessment; numerical or facial

Fall Risk – If patient assessed for risk (question 1 & 2) or performance based test (Get up and Go Test) Visual – If patient referred for visual screening test; Snellen, Ophthalmology, Optometry Hearing – If patient referred to ENT / Audiology; please see attached hearing tool Alcohol Screening – please refer to Cage or SMAST – G Tobacco Screening – Was it addressed? Physical Activity Counseling – Was it addressed? Colorectal Cancer Screening – If patient referred for colonoscopy, sigmoidoscopy or FOBT Breast Cancer Screening – If patient referred for mammogram Elderly Mistreatment – please see Elder Mistreatment Assessment Tool Advanced Directives – Was it addressed?