Comprehensive Geriatric Assessment
From assessment to integrated care plan
Convert multidomain information into a prioritised problem list. Assign actions, ownership, timescales and review points.
Learning objectives
• Convert multidomain information into a prioritised problem list. • Assign actions, ownership, timescales and review points. • Communicate the plan across settings and disciplines. • Use iteration and follow-up so CGA remains a process rather than a static document.
Learner handbook (PDF)
Open source ↗Why this module matters
The final skill is synthesis: converting information into priorities, actions, ownership, review and communication across settings.
Core teaching
The endpoint of CGA is not a completed assessment; it is a prioritised and coordinated plan. A useful plan states the problem, what matters to the person, agreed action, owner, timescale, monitoring and review. It also records uncertainty and what would trigger reassessment.
CGA is iterative. Some problems resolve, others emerge, and goals can change. Transitions are therefore high-risk points. Information must move with the person and responsibilities must be explicit across hospital, primary care, community, rehabilitation and social care.
The final quality check is whether another clinician or team can understand what matters, what has been decided, what remains unresolved, what they are expected to do and when the plan should be reviewed.
Case step
Mrs Morgan improves after treatment and rehabilitation. The final CGA must integrate medicines changes, mobility goals, nutrition, hearing support, home modifications, daughter’s availability, future wishes and named community follow-up.
Interactive element
Integrated care-plan builder: learner completes problem/goal/action/owner/review fields and must resolve missing ownership before submission.
Practice points
- Document baseline as well as current state.
- Use collateral information when history is incomplete.
- Convert every important finding into an action or explicit decision not to act.
- State uncertainty rather than disguising it as a score.
- Name ownership and review whenever the plan crosses teams or settings.
Reflection prompt
What one change would make your current CGA documentation more actionable across transitions?
