inpatient / palliative and geriatrics

Geriatric 5M's Assessment

Last Updated: 1/8/2023

#Geriatric Assessment 5M's

#Multimorbidity
--Geriatric ROS: 
-- Vision/Hearing: ***
-- Nutrition/Appetite/Weight: ***
-- Chewing/swallowing/dental: ***
-- Bowel/Bladder: ***
-- Pain: ***
-- Wounds: ***
-- SDOH: ***

#Mind
-- Mood: ***
-- Memory: ***
-- Social Support: ***
-- Sleep: ***
-- Safety Concern: *** stove, wandering, etc
-- Agitation: ***

#Mobility
-- Living Situation: ***
-- Falls: *** past year, unsteadiness
-- ADLs: *** bathing, dressing, transferring, toileting, eating
-- IADLS: *** finances, cooking, shopping, housekeeping
-- Assistive Devices: ***
-- Exercise: ***
-- Caregivers/Home Services: ***
-- Transportation: ***
-- Driving: *** accidents, violations

#Medications
-- Med Rec: ***
-- System for Taking Meds: ***
-- Adherence: ***
-- Side Effects: ***
-- De-escalation: ***

#Matters Most
-- Medical Decision Maker: ***
-- Brings life joy or meaning: ***
-- Relationships and Connections: ***
-- Health Goals and Focus: ***
-- ACP Documents: ***

Get Template PDF

PDF coming soon!

Thanks to Dr. Eva Szymanski and Dr. Rachel Miller for sharing this template.