An AI medical scribe for geriatric medicine

A geriatric assessment covers more ground than almost any other visit: function, memory, mood, falls, continence, a long medicine list and plans for the future, often with a daughter or carer adding to the story. ClearPass transcribes the whole conversation, separates the speakers, and drafts a note you can check against what you found.

The ground a geriatric note covers

A comprehensive geriatric assessment is only useful if the next person can see the baseline. Write the facts in a form that allows comparison: scores with their date, distances in metres, falls with their number and circumstances.

• Function: personal care, dressing, continence, transfers; then shopping, cooking, finances, medicines. Who helps, and how often.
• Cognition: the screening test used and the score, the domains lost, how change has shown itself at home, and whether capacity was assessed for a specific decision.
• Mood, sleep, appetite and weight change.
• Falls: how many in the last year, what happened, injuries, time on the floor, fear of falling, footwear, eyesight, postural blood pressure.
• Gait and balance findings, walking aid, a timed walking or standing test if you used one, and a frailty score.
• Medicines: the full list, what the patient actually takes, anticholinergic and sedative burden, and what you stop or reduce.
• Social situation, carer strain, home hazards, and advance care planning wishes in the patient's own words.

Example: falls clinic

History from patient and daughter: Woman in her eighties, three falls in six months, all indoors at night on the way to the bathroom. No loss of consciousness. Lay on the floor 40 minutes after the last fall. Nocturia three times a night. Daughter reports more forgetfulness over a year, repeating questions.
Medicines: amlodipine 10 mg, bendroflumethiazide 2.5 mg, zopiclone 7.5 mg at night, oxybutynin 5 mg twice daily, paracetamol.
Examination: Lying BP 148/78, standing at 3 minutes 122/70 with light-headedness. Slow gait with a stick, reduced step length. Cognitive screening score 22 of 30, losing points on recall and attention. Clinical frailty score 5.
Impression: Recurrent falls with orthostatic hypotension, sedative and anticholinergic burden, nocturia, and possible mild cognitive impairment.
Plan: Stop zopiclone with a taper, stop oxybutynin, stop bendroflumethiazide. Home physiotherapy and occupational therapy referral. Pendant alarm discussed. Memory clinic referral. Review in 6 weeks with repeat postural BP.

Templates and structures for older patients

Geriatrics has no guided template group of its own. Internal Medicine includes a Medication / polypharmacy review case, Neurology includes Dementia / cognitive decline, and Rehabilitation & Therapy includes Occupational therapy; use them when a visit centres on one of those problems.

For a full assessment, Full headings with Detailed length keeps the breadth. Many geriatricians prefer a domain-based layout: function, cognition, mood, falls, continence, nutrition, medicines, social, future planning. Save it once with My own structure and reuse it. The Problem list structure suits a follow-up where five or six issues each need a line of plan.

Letters and documents

• Referral letters to therapy teams, memory clinic or community nursing; see the referral letter template.
• A medical report supporting care arrangements or a needs assessment, written from the same visit.
• Patient instructions for the patient and family: which medicines stopped and why, what to do after a fall, when to call.
• A letter back to the family doctor with a clear medicines list, so the changes stick.
• For visits in the patient's home, see AI scribe for home visits.

Reviewing the draft

1. Check who said what. Transcribe separates speakers, but check the note attributes the carer's observations to the carer and the patient's account to the patient.
2. Check the medicine list line by line. Stopped, reduced and continued must be unambiguous. The Numbers check marks any dose that was never said.
3. Check scores and blood pressures. Cognitive scores and postural readings carry the diagnosis; compare them with your own notes.
4. Check the wording on capacity and wishes. Keep it to what was assessed and what the patient said, for the decision in question.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

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