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

2. 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

3. 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)

4. 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)

5. 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

6. 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?