DEMENTIA CARE PLAN

Patient: [Name, date of birth]
Visit date: [Date]
Visit type: [Cognitive assessment and care planning visit, or plan review]
Present: [Patient, caregiver, other family, interpreter]
History from: [Patient, caregiver or another informant, records, other clinicians]
Clinician: [Name, credentials]

DIAGNOSIS AND COGNITIVE TESTING
Changes noticed: [What the patient and caregiver have noticed, when it started, and how fast it is changing]
Cognitive tests: [Each tool with its score, date, and the patient's years of schooling: MoCA, Mini-Cog, MMSE, or another]
Workup: [Blood tests, brain imaging, hearing and vision checks, mood screen, with results]
Diagnosis: [Mild cognitive impairment or dementia, and the likely cause: Alzheimer's, vascular, Lewy body, frontotemporal, or mixed]
Stage: [Mild, moderate, or severe, and any staging scale used]
How it was shared: [Words used, who was there, the patient's reaction and questions]

FUNCTION
Self-care: [Bathing, dressing, toileting, transfers, continence, eating: on their own, with prompting, or with help]
Household tasks: [Money, medicines, meals, shopping, transport, phone, housework: who does each now]
Mobility and falls: [Walking aid, falls in the past year, injuries]
Hearing and vision: [Aids worn, and checks due]

MEDICATIONS
Reconciled list: [Each medicine and dose, the source checked, and who manages them at home]
Medicines that cloud thinking: [Anticholinergics, sedatives, sleeping pills, opioids: stopped, tapered, or kept, and why]
Dementia medicine: [Cholinesterase inhibitor or memantine: started, continued, changed, or not used, and why]
Dose steps and side effects: [Starting dose, when to raise it, and what to watch for]
Help with medicines: [Blister packs, organizer, reminders, or supervised doses]

BEHAVIOR AND MOOD
Symptoms: [Low mood, anxiety, apathy, agitation, sleep change, hallucinations, delusions, wandering]
Pattern and triggers: [Time of day, how often, what sets it off, what settles it]
Causes checked: [Pain, constipation, infection, hearing loss, medicines, sleep, delirium]
Non-drug plan: [Routine, activity, light and noise, how the caregiver responds]
Medicine for symptoms: [Started or not, the reason, the risks discussed, and the date to review or stop]

SAFETY
Driving: [Driving, stopped, or referred for a driving assessment, and any report the rules where you practice require]
Firearms: [None, locked, or removed, and who holds the key]
Wandering: [Episodes, ID bracelet, door alarm, location device]
Home and cooking: [Stove, fall hazards, living alone, emergency call system]
Money and scams: [Who helps with finances, bank alerts, recent losses]
Abuse or neglect: [Asked, with the patient alone where possible; concerns and action]

CAREGIVER AND SUPPORTS
Main caregiver: [Name, relationship, lives with the patient or not, phone]
Caregiver strain: [Sleep, health, work, mood, and any strain scale score]
Education given: [Topics covered and materials]
Support for the caregiver: [Respite, support group, counseling, their own clinician]
Community services: [Alzheimer's organization, day program, home care, meals, transport: referrals and dates]

ADVANCE CARE PLANNING
Capacity today: [For which decisions, and how you judged it]
Decision-maker: [Name, relationship, and how named]
Legal documents: [Powers of attorney and advance directive: on file, or steps to complete them]
Conversation: [Held today, booked, or recorded in a separate advance care planning note]

OTHER CONDITIONS
Conditions that affect the plan: [Blood pressure, diabetes, heart disease, stroke, sleep, alcohol, weight, continence, pain]
Changes for them: [Targets eased, medicines simplified, tests stopped]

FOLLOW-UP
Next contact: [Phone call or visit, date, and who]
Plan review and retesting: [Date for review and repeat cognitive test]
Call sooner if: [Sudden worse confusion, a fall, side effects, or the caregiver can't cope]
Copies to: [Patient, caregiver, other clinicians, and services]

Signed: [Clinician name, credentials, date]