SOAP note examples › Geriatrics

Geriatric SOAP Note Example: Urinary Incontinence and Medication Review

A geriatrics note where function, falls, cognition and medications matter as much as the diagnosis, and goals of care are part of the plan.

By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026

Setting: Outpatient geriatrics visitPatient: Fictional patient: 81-year-old woman, with her daughter

SSubjective

Concern
"I can't make it to the bathroom in time." History from the patient and her daughter, who helps with medications.
Function
ADLs: independent in bathing, dressing, transferring and feeding; continence impaired. IADLs: daughter has managed finances and medications for a year; she still cooks simple meals. Stopped going to her church group for fear of leaking.
Falls
One fall 2 months ago at night, hurrying to the bathroom; no injury.
Cognition / mood
Daughter notices mild forgetfulness; no getting lost. Patient feels embarrassed but not depressed (PHQ-2 negative).
Continence, sleep, nutrition
8 months of sudden urgency with leakage several times a day, worse in the morning and after coffee. Up 3 times a night to urinate. Uses 3 pads a day. Little leakage with coughing. No burning, blood in urine or fever. Bowel movements daily. Drinks 3 cups of coffee and a lot of water in the evening. Weight stable.
Medications
Amlodipine 5 mg daily. Oxybutynin 5 mg twice daily (started at urgent care 3 months ago). Omeprazole 20 mg daily (for years, no current reflux symptoms). Vitamin D3 1,000 units daily. Acetaminophen as needed.
Social
Lives alone in a two-story house; daughter visits daily.
Goals of care
Wants to stay in her own home. No advance directive.

OObjective

Vital signs
BP 132/74 seated, 128/72 at 1 minute standing, 126/70 at 3 minutes (no orthostatic drop). HR 76. Weight 64 kg, stable.
Exam
Abdomen soft, no suprapubic fullness. Pelvic: atrophic vaginal tissue; no prolapse beyond the hymen. Rectal: no stool impaction. Gait slow but steady.
Screens
Mini-Cog 3/5 (recalled 1 of 3 words; clock normal). Timed Up and Go: 13 seconds. PHQ-2: 0.
Data
Urinalysis: negative for leukocyte esterase, nitrites and blood. Post-void residual by bladder scan: 40 mL. Creatinine 0.9, glucose 104.

AAssessment

Problems
1. Urgency urinary incontinence (overactive bladder). Contributors: caffeine and evening fluids; vaginal atrophy may add. No infection, retention or significant prolapse.
2. Polypharmacy with potentially inappropriate medications (Beers criteria): oxybutynin is strongly anticholinergic and may worsen memory and fall risk; long-term omeprazole without a current indication.
3. Possible cognitive impairment (Mini-Cog 3/5, daughter's observations); reassess off the anticholinergic.
4. Fall risk: one fall in the past year related to nighttime urgency.
5. Advance care planning not yet done.

PPlan

Medication changes
Stop oxybutynin. If medication is still needed after a behavioral trial, consider mirabegron 25 mg daily (check BP). Deprescribe omeprazole: 20 mg every other day for 2 weeks, then stop; use as needed for heartburn. Discussed low-dose vaginal estrogen for atrophy; she will consider it.
Safety
Bladder training and timed voiding every 2 hours while awake; cut caffeine to 1 cup in the morning; limit fluids 2-3 hours before bed while keeping total intake adequate. Night-light path to the bathroom and a bedside commode.
Referrals
Pelvic floor physical therapy; PT for gait and balance; OT home safety evaluation.
Advance care planning
Discussed; she would like her daughter as health care proxy. Advance directive form given; revisit next visit.
Follow-up
6 weeks with a 3-day bladder diary. Repeat cognitive screen in 2-3 months off oxybutynin.

Fictional patient, written for learning. Follow your program's and facility's documentation standards.

Why this note works

What students often miss

Geriatrics SOAP note template

Function and goals matter as much as diagnoses. Look for the geriatric syndromes.

SSubjective

Concern
From patient and caregiver; name the source.
Function
ADLs, IADLs, recent change.
Falls
Number, circumstances, injuries.
Cognition / mood
 
Continence, sleep, nutrition
 
Medications
Every medication, including OTC and supplements.
Social
Living situation, caregiver, supports.
Goals of care
 

OObjective

Vital signs
Including orthostatics when relevant; weight trend.
Exam
Including gait and balance.
Screens
Cognitive, mood, gait (e.g. Timed Up and Go).
Data
 

AAssessment

Problems
Including geriatric syndromes: falls, cognitive impairment, polypharmacy.

PPlan

Medication changes
Including deprescribing.
Safety
Fall prevention, home safety.
Referrals
PT/OT, social work.
Advance care planning
 
Follow-up
 
Download the Geriatrics template (PDF) All templates

Now write one yourself

Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.

Your first case is free · No card required

More SOAP note examples

Internal MedicineCellulitis, Hospital Day 2Family MedicineAcute Bronchitis plus Preventive CareEmergency MedicineAcute AppendicitisPediatricsAcute Gastroenteritis with Mild DehydrationOB/GYN36-Week Prenatal VisitPsychiatryPanic Disorder, Initial EvaluationNeurologyBell's PalsyCardiologySevere Aortic StenosisPulmonologyCommunity-Acquired Pneumonia, OutpatientOrthopedicsLateral Ankle SprainDermatologyAllergic Contact Dermatitis (Poison Oak)SurgeryPost-Op Day 2 After Laparoscopic Appendectomy

New to SOAP notes? Start with How to Write a SOAP Note, then How to Present a Patient.