AI Scribe for Geriatrics
Transcribe Health drafts your assessment and follow-up notes while you work, so the med list, the cognitive and functional findings, and the care plan are on the page before you leave the room.
Photo: Vitaly Gariev / Unsplash
Geriatric documentation, from the assessment to the care plan
A geriatric visit rarely stays on one problem. A single appointment can move through polypharmacy, memory concerns, a recent fall, mood, continence, hearing, and what the family is seeing at home. Each thread has to land in the note with the actual finding behind it, not a one-line summary, because the next clinician and the billing reviewer both read it.
The comprehensive assessment is the dense one. Cognition, mood, ADLs and IADLs, gait and balance, nutrition, medications, and social supports each need their own findings, and the medication reconciliation alone can run twenty lines with a prescriber and an indication for every entry. Done by hand, that is either typing through the visit or staying late to write it up.
Transcribe Health listens to the visit and drafts a note that keeps those threads separate: the MoCA score in cognition, the ADL dependencies in function, the reconciled med list with your deprescribing rationale, and the goals-of-care discussion in the patient's and family's own terms. You read it and sign. Nothing is filed without you.
Documentation Challenges in Geriatrics
- 1
Reconciling long medication lists across multiple prescribers and flagging Beers criteria drugs, drug-drug interactions, and candidates for deprescribing in the note
- 2
Recording cognitive and functional status in the detail an assessment needs: MoCA or MMSE scores, ADL and IADL dependencies, gait and fall history, and caregiver-reported change
- 3
Capturing goals-of-care and advance care planning conversations, including surrogate decision-makers and code status, alongside the interplay of several chronic conditions
How Transcribe Health Helps Geriatrics
Comprehensive Assessment Notes
Turns a long visit into a structured note that keeps cognition, function, mobility, mood, and social supports in their own sections.
Medication Review Documentation
Records the reconciled medication list, dose changes, and deprescribing decisions with the reasoning you give, so nothing is lost between visits.
Goals-of-Care Capture
Writes up advance care planning discussions, code status, and surrogate decision-makers from the conversation as it happened.
A geriatric note, captured in real time
An abridged comprehensive assessment for a falls and polypharmacy visit, drafted the way you would see it before signing.
82-year-old woman brought in by her daughter after two falls in the past three months, both at home without loss of consciousness. Reports lightheadedness on standing. Daughter notes she is more forgetful over the past year, misses medication doses, and no longer manages her own finances. Sleep is fair. Appetite reduced, with roughly 8 pounds of unintended weight loss. Lives alone; daughter visits three times a week. Current medications include amlodipine, hydrochlorothiazide, metoprolol, zolpidem, oxybutynin, and diphenhydramine as needed for sleep.
BP 138/78 seated, 116/70 standing with a 20 mmHg systolic drop and reproduction of symptoms. HR 68. BMI 21. Alert, no acute distress. MoCA 21/30, with points lost on delayed recall and visuospatial tasks. Timed Up and Go 16 seconds with a slow, wide-based gait. ADLs independent for feeding and toileting; requires assistance with bathing. IADLs impaired for medications, finances, and transportation. Feet without ulceration. Vision grossly reduced; last exam over two years ago.
1) Recurrent falls, multifactorial: orthostatic hypotension, gait impairment, polypharmacy, and reduced vision. 2) Polypharmacy with several Beers criteria medications (zolpidem, oxybutynin, diphenhydramine) contributing to fall and cognitive risk. 3) Mild cognitive impairment versus early major neurocognitive disorder, MoCA 21/30, with IADL decline. 4) Unintended weight loss, cause not yet established. 5) Orthostatic hypotension, likely medication-related.
Deprescribe zolpidem, oxybutynin, and diphenhydramine, with a taper plan for zolpidem and sleep hygiene counseling given to patient and daughter. Reduce hydrochlorothiazide and reassess orthostatic vitals in two weeks. Referral to physical therapy for gait and balance training and home safety evaluation. Basic labs today including CBC, CMP, TSH, B12, and HbA1c to work up weight loss. Refer to ophthalmology for updated vision assessment. Discussed advance care planning; patient wishes daughter as surrogate decision-maker and will complete a health care proxy. Follow up in two weeks.
Illustrative example. Not a real patient encounter.
Built for geriatric coding and your EMR
Notes capture the history reviewed, the number and severity of chronic conditions, and the risk that back up your E/M level, along with the elements a wellness visit, cognitive assessment, or advance care planning service requires. That is the detail auditors look for, and the first thing to slip when charting is rushed.
- 99214 / 99215Established-patient follow-up, moderate to high complexity
- 99204 / 99205New-patient assessment, moderate to high complexity
- G0438 / G0439Medicare Annual Wellness Visit, initial and subsequent
- 99483Cognitive assessment and care plan for a patient with cognitive impairment
- 99497Advance care planning, first 30 minutes
- 99495 / 99496Transitional care management after hospital or facility discharge
- R29.6Repeated falls
- G31.84Mild cognitive impairment
- I95.1Orthostatic hypotension
- R63.4Abnormal weight loss
- Z79.899Other long-term (current) drug therapy, used to flag polypharmacy monitoring
Fits the workflow you already have
Drafts drop into the major EMRs geriatric and primary care practices run on: Epic, Oracle Health (Cerner), athenahealth, and PointClickCare for those working in long-term care. You get whatever note type you are working in, a comprehensive assessment, a wellness visit, or a transitional care follow-up. It writes up the MoCA or MMSE score, the ADL and IADL findings, and the medication changes you dictate. It does not calculate risk scores or reconcile the med list for you; you make the clinical call and it records it.
Geriatrics AI scribe questions
Does it understand geriatric assessment terminology and drug names?
Can it handle a long visit with several problems?
Does it document goals-of-care and advance care planning?
How is patient information protected?
Will it help with coding and audit defensibility?
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