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Caredevo
Health Assessment — 75+, ATSI, Disability

A Health Assessment that finds everything. Care plan that acts on it.

Your patient is 73 with AF, previous stroke, high fall risk, osteoporosis, post-TURP urinary incontinence from BPH, no advance care directive, overdue screenings, and he lives alone. Caredevo turns that one assessment into a structured care plan — every problem named, every goal set, every referral coordinated.

This is not a faster health check form. This is a care plan that maps every issue and carries it forward.

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Caredevo Health Assessment care planning workflow for older patients in Australian general practice

The real picture

One consultation. Twelve active problems. One checkbox form.

A standard health assessment finds the list. It does not build the plan.

What Caredevo does

Each problem. Its own goal, tasks, and referral.

A care plan that acts on assessment findings — not just documents them.

Year to year continuity

Next year's assessment starts with progress — not a blank page.

Goals tracked, screenings booked, advance care planning updated.

Who is eligible

MBS-funded Health Assessments in Australian general practice

75 years and over

  • Annual health assessment
  • MBS items 700, 701, 703, 705, 707
  • Comprehensive review of health, function, and preventive care
  • Nurse or GP-led assessment supported

Aboriginal and Torres Strait Islander

  • Available from any age
  • MBS item 715
  • Annual comprehensive review
  • Covers chronic disease, social determinants, preventive care

People with intellectual disability

  • Structured annual health check
  • MBS items 92004, 92011
  • Covers physical, mental, and functional health
  • Carer and support worker involvement supported

The assessment that cannot hold everything

David has twelve active issues. The form has room for a list.

David is 73. He has atrial fibrillation, a previous stroke, hypertension, and is at high risk of falls. His left hip was replaced four years ago. He has osteoporosis. He lives alone, has no medical power of attorney, and no advance care directive. He had a TURP for BPH and is now suffering from post-operative urinary incontinence. He is slightly depressed. He is overdue for his flu vaccine and COVID booster. His BMD repeat is due next year, and PSA surveillance is overdue given his BPH and TURP history. And he needs a disability parking permit.

The consultation runs 30 minutes. The GP completes the health assessment form. Most of the list is captured. A few referrals are written. David leaves with a follow-up appointment. The care plan does not exist.

What was in the assessment — and never became a structured action

  • AF — anticoagulation reviewed but no structured follow-up plan
  • Stroke risk — CHA₂DS₂-VASc not documented, no cognitive screen
  • Hypertension — orthostatic hypotension not checked
  • Falls risk — no FRAT administered, no OT or physio referral
  • Osteoporosis — treatment not confirmed, BMD recall not booked
  • Lives alone — no emergency contact recorded, no PERS discussed
  • No ACD or Medical POA — acknowledged, deferred to next time
  • Urinary incontinence — noted, no bladder diary or continence referral
  • Flu and COVID vaccines — overdue, not administered today
  • BMD and PSA surveillance — noted but not booked
  • Disability parking permit — not completed at this visit
  • Low mood — GDS not administered, no plan documented

Every one of these was present in the assessment. None became a structured goal with a task and a referral.

Why this keeps happening

The Health Assessment was designed to find problems. Not to build the care plan.

The form is useful. But without a tool that turns assessment findings into structured, problem-level care plans, the list stays a list — and most of it goes unactioned.

30 minutes to assess 12 active clinical issues

An older patient with atrial fibrillation, previous stroke, high fall risk, osteoporosis, incontinence, and no advance care directive is not one clinical problem. A single health assessment consultation cannot address all of it without a structured tool.

The checklist captures the problem. Nothing captures the plan.

Health assessment forms are good at generating a list. They do not give each problem a named goal, a specific task, or a coordinated referral. The list stays on paper while the patient goes home with a generic follow-up.

Preventive care items are noted — then forgotten

Overdue flu vaccine. COVID booster. BMD repeat next year. PSA surveillance due. Bowel cancer screening. These are documented in the assessment and then fall through the gap between visits if there is no structured follow-up mechanism.

Advance care planning is always next time

No advance care directive. No medical power of attorney. These are critical for a 73-year-old living alone with AF and previous stroke. But they are consistently deferred because there is no structured prompt and no clear process to follow within the consultation.

The cost of an unactioned assessment

When David leaves with a follow-up appointment but no structured care plan, the fall happens before the physiotherapist referral is made. The advance care directive does not exist when it is needed at 2am in the emergency department. The PSA surveillance is deferred for another twelve months. The incontinence continues to limit his mobility and confidence — and feeds directly into the depression that was noted but not addressed.

These are not worst-case outcomes. They are the predictable consequence of identifying problems without building a plan to act on them.

What a standard Health Assessment misses

  • Individual goals per clinical problem
  • Task list per identified issue
  • Referral mapped to each problem
  • Advance care planning structured action
  • Preventive care booked — not just noted
  • Annual review framework with carry-forward

David — 73 yo, 75+ Health Assessment

Twelve problems. Twelve goals. One structured care plan.

This is what a problem-level health assessment care plan looks like — every identified issue named, structured, and given a clear clinical direction.

Goal

Maintain anticoagulation within therapeutic range, monitor heart rate, and minimise AF-related stroke and bleeding risk.

Tasks

  • Review anticoagulation — NOAC dose, adherence, and renal function
  • ECG to assess rate and rhythm
  • Calculate CHA₂DS₂-VASc score and document
  • Bleeding risk review — HAS-BLED score, review NSAIDs and interacting medications
  • Discuss AF symptoms and action plan for palpitations or breathlessness

Referral

Cardiologist — annual or as-needed review for AF management. Pharmacist HMR for anticoagulation and polypharmacy review.

Goal

Minimise recurrent stroke risk and monitor for cognitive and functional changes related to prior stroke.

Tasks

  • Confirm anticoagulation in place for AF-related stroke prevention
  • Cognitive screening — MMSE or MoCA at this visit
  • Blood pressure target review — aim <130/80 in post-stroke
  • Assess residual neurological deficits and functional impact
  • Document history clearly for any future emergency presentations

Referral

Neurologist if new neurological symptoms or cognitive decline detected. Stroke rehabilitation review if not recently completed.

Goal

Maintain BP below 130/80 mmHg while minimising orthostatic hypotension and falls risk from antihypertensives.

Tasks

  • Measure seated and standing BP — assess orthostatic drop
  • Review antihypertensive regimen for falls-risk medications
  • Home BP monitoring education — frequency and recording
  • Dietary salt reduction and lifestyle advice
  • Review other medications interacting with BP (NSAIDs, decongestants)

Referral

Pharmacist HMR to review antihypertensive regimen for falls and drug interaction risk.

Goal

Reduce fall risk score through environmental, physical, and medication interventions within 6 weeks.

Tasks

  • Administer Falls Risk Assessment Tool (FRAT) or equivalent
  • Review all medications contributing to fall risk — sedatives, antihypertensives, diuretics
  • Footwear assessment — advise on low-heel, non-slip footwear
  • Vision check — refer if not reviewed in past 12 months
  • Discuss home hazards — rugs, lighting, bathroom rails

Referral

Physiotherapist — balance and lower limb strength program. Occupational therapist — home safety assessment and modifications. Optometrist — vision review.

Goal

Optimise bone density and reduce fracture risk with appropriate pharmacological support and monitoring.

Tasks

  • Confirm current osteoporosis treatment — bisphosphonate or denosumab, adherence
  • Calcium (1200mg/day) and vitamin D (at least 800 IU/day) supplementation confirmed
  • Dental review before or if initiating bisphosphonate — MRONJ risk
  • Schedule repeat BMD for next year — book now
  • Review hip replacement site — any pain, instability, or functional concern

Referral

Rheumatologist or endocrinologist if osteoporosis treatment needs escalation. Orthopaedic review if hip replacement symptoms present.

Goal

Establish a social safety network and emergency response plan within 4 weeks.

Tasks

  • Discuss and recommend Personal Emergency Response System (PERS / medical alarm)
  • Identify emergency contact — family, friend, neighbour — document in notes
  • Assess loneliness and social connection — brief screening (UCLA-3 or similar)
  • Discuss community support options — senior centres, social programs
  • Register with My Aged Care if not already done

Referral

ACAT — Aged Care Assessment Team for home support package eligibility. Social worker for community connection and support coordination.

Goal

Complete an Advance Care Directive and appoint a Medical Power of Attorney within 3 months.

Tasks

  • Discuss advance care planning — values, goals of care, and wishes
  • Provide state-specific ACD form and completion guide
  • Identify person to appoint as medical decision-maker (Enduring Power of Attorney — Medical)
  • Book dedicated ACD discussion appointment if not completed today
  • Document discussion in medical record — patient engaged and forms provided

Referral

Advance Care Planning Australia — advancecareplanning.org.au. Legal aid or community legal centre for POA documentation. Palliative care ACP facilitator if complex goals of care.

Goal

Manage post-TURP urinary incontinence, exclude urinary retention, and improve quality of life through male pelvic floor and lifestyle interventions within 8 weeks.

Tasks

  • Bladder diary — 3-day diary for frequency, urgency, leakage pattern and volume
  • Post-void residual bladder ultrasound — exclude incomplete emptying and retention
  • MSU — exclude urinary tract infection as contributing factor
  • Review medications contributing to incontinence or retention — diuretics, anticholinergics, alpha-blockers
  • Male pelvic floor exercise program — written instructions provided, consider physiotherapy-guided program

Referral

Urologist — post-TURP follow-up, urodynamics if incontinence persists beyond 3 months. Continence physiotherapist — male pelvic floor rehabilitation program.

Goal

Administer overdue flu and COVID booster vaccination at this visit or within 2 weeks.

Tasks

  • Check Australian Immunisation Register (AIR) — confirm vaccination history
  • Administer influenza vaccine today (annual)
  • Administer COVID booster today if available, or book within 2 weeks
  • Check pneumococcal vaccination status — due if not completed or booster overdue
  • Update AIR and document in medical record

Referral

Nil — administer in-clinic. Arrange community pharmacist administration for COVID booster if clinic stock unavailable.

Goal

Complete all due preventive screening within correct timeframes and establish recall reminders for future items.

Tasks

  • PSA surveillance — discuss and arrange given history of BPH and TURP; document shared decision-making
  • Set recall for repeat BMD — next year, note in care plan
  • Bowel cancer screening — FOBT kit if in program age range; discuss colonoscopy if risk factors or positive FOBT
  • Skin check — full skin examination if not recently completed
  • Document all screening dates and upcoming due dates in care plan

Referral

Urologist — PSA surveillance and prostate health monitoring post-TURP. Radiology referral for BMD (next year). Gastroenterology referral if FOBT positive.

Goal

Complete and submit disability parking permit application at this visit.

Tasks

  • Confirm patient meets eligibility — permanent and significant mobility restriction
  • Complete medical certificate for parking permit (state-specific form)
  • Provide completed certificate to patient for council lodgement
  • Advise patient on application process and expected processing time

Referral

No external referral required — GP completes medical certificate. Patient lodges with local council or state authority.

Goal

Screen, assess, and establish a support plan for mild depressive symptoms within 4 weeks.

Tasks

  • Administer Geriatric Depression Scale (GDS-15) or PHQ-9
  • Assess contributing factors — social isolation, functional loss, chronic pain, medication
  • Review medications that may contribute to low mood — beta-blockers, statins, benzodiazepines
  • Discuss physical activity for mood — encourage walking group or exercise program
  • Safety assessment — passive suicidal ideation or hopelessness screen

Referral

Psychology referral under MHCP if criteria met. Social worker for social determinants of mood. Exercise physiologist for structured movement program. Consider geriatric psychiatry if severe or medication-resistant.

Why structure matters at this level

Every problem above was identified in David's consultation. Without naming each one and giving it a goal, they remain as notes — not as clinical actions.

What this gives the allied health team

Physiotherapist, OT, continence nurse, social worker — each receives a referral that names the specific problem and goal they are being asked to address.

What this gives next year's assessment

Goals to measure. Screenings already booked. Advance care directive status documented. A plan that carries forward rather than starting from scratch.

Caredevo vs other AI scribes

Other AI scribes document the assessment faster. Caredevo builds the care plan.

Standard AI scribes reduce documentation time. Caredevo structures the findings into a problem-level care plan that every treating clinician can act on.

Capability
Standard AI scribe
Caredevo

Faster health assessment documentation

Structured problem list from assessment findings

Individual goal per identified problem

Tasks and actions per problem area

Referral mapped to each clinical issue

Preventive care and screening action items

Advance care planning documentation

Aged care and home support referrals

Follow-up schedule with named review dates

Standard AI scribes are built for one consultation. Caredevo is built for the patient's ongoing health across every annual assessment.

How Caredevo works

One assessment. One note. A care plan that maps the full picture.

Caredevo does not replace your clinical judgement. It gives you the structure to turn assessment findings into actionable care — at the problem level, for every problem.

01

Capture the assessment

Record, dictate, Smart Paste, or type the assessment findings. Caredevo builds one structured consultation note from the full clinical picture.

02

Dissect into individual problems

Each identified issue — chronic condition, fall risk, social safety, preventive care, screening, advance care planning — becomes its own clinical entry.

03

Goal, task, and referral per problem

Every problem has a named goal, specific tasks, and a referral to the right service — GP, allied health, specialist, aged care, or community support.

04

A framework for every annual review

The care plan becomes the thread from one annual assessment to the next — goals tracked, screenings booked, advance care plans updated.

Platform features

Everything built around structured health assessment care

Health Assessment

Problem-by-problem Health Assessment care plan

Caredevo dissects assessment findings into individual clinical problems — each with a goal, tasks, and referral — turning the Health Assessment from a form into a structured ongoing care framework.

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Caredevo Health Assessment structured care plan for elderly patients in Australian general practice

Why GPs choose Caredevo for Health Assessments

A care plan that acts on every finding.

  • Every identified problem becomes a clinical entry. Fall risk, advance care planning, overdue vaccinations, screening — each gets a goal and a task, not just a note.
  • Coordinated referrals across the full care team. Physiotherapy, OT, continence nurse, social worker, aged care — each referral mapped to the problem it addresses.
  • Preventive care booked — not noted. Mammogram, BMD, cervical screening, and vaccinations become action items with dates and booking tasks — not entries that sit on a list until next year.
  • Advance care planning structured at every assessment. ACD and Medical POA status documented, prompts built in, resources provided — not deferred indefinitely.
  • Next year's assessment starts informed. Goals carry forward. Screenings are pre-booked. The assessment builds on prior care rather than restarting from a blank page.
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Example structured output — David

Assessment

73-year-old male, AF, previous stroke, hypertension, high fall risk, osteoporosis, post left hip replacement, lives alone, no ACD or POA, post-TURP urinary incontinence from BPH, low mood, overdue vaccinations and screening

Care plan

12 structured problems — each with named goal, task list, and referral to the appropriate service

Referrals generated

Cardiologist, physiotherapist, OT, optometrist, urologist, continence physio, social worker, ACAT, pharmacist HMR

In-visit actions completed

Flu vaccine administered. COVID booster booked. Disability parking permit medical certificate completed. ACD forms provided.

Annual review framework

BMD and PSA surveillance recalls set. Goals documented for next year's assessment carry-forward.

Caredevo is an assistant tool only. Final clinical judgement and documentation remain yours.

Ready to try it?

A Health Assessment that builds the care plan — not just the list

Turn one consultation into a structured care plan — every problem named, every goal set, every referral coordinated, and every screening booked.

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Frequently asked questions

Answers for GPs considering Caredevo for structured health assessment care planning.

A Health Assessment is a structured, comprehensive review of a patient's health — including medical history, current conditions, medications, functional status, preventive care, screening, and psychosocial wellbeing. MBS-funded assessments are available for Australians aged 75 and over, Aboriginal and Torres Strait Islander people of any age, and people with an intellectual disability.
An older patient with multiple chronic conditions, social risk factors, and overdue preventive care may have 10 to 15 separate clinical issues requiring action. A standard health check form captures the list. It does not give each issue a named goal, a task, and a referral — leaving most of the clinical picture unaddressed after the consultation.
Caredevo turns the assessment consultation into one structured note, then generates a problem-level care plan — each identified issue gets its own goal, tasks, and referral. The output supports GPCCMP content, preventive care action plans, and coordinated referrals to allied health, aged care, and specialist services.
Australians aged 75 and over (MBS items 700, 701, 703, 705, 707), Aboriginal and Torres Strait Islander people from age 0 (MBS item 715), and people with an intellectual disability (MBS items 92004, 92011) are eligible for structured, MBS-funded health assessments in general practice.
Yes. After capturing the assessment findings, Caredevo structures each identified problem — chronic disease, social risk, preventive care, screening, advance care planning, functional decline — into a care plan with named goals, tasks, and referrals to the appropriate service or clinician.
Caredevo supports structured documentation of advance care planning discussions, including whether an Advance Care Directive exists, who holds Medical Power of Attorney, and what the patient's documented wishes are. These become part of the structured care plan and can be reviewed at subsequent visits.
Yes. Overdue vaccinations, PSA surveillance, bone mineral density scans, bowel cancer screening, and other surveillance items can be documented as individual action items — each with a goal, a booking task, and a referral — so they are acted on rather than noted and forgotten.
Falls risk is structured as a separate clinical problem with its own goal, tasks — falls risk assessment, medication review, vision and footwear checks — and referrals to physiotherapy, occupational therapy, and optometry as appropriate.
Yes. Caredevo supports documentation of referrals to ACAT (Aged Care Assessment Team), My Aged Care registration, social work, home care packages, and community services as part of the Health Assessment care plan.
Yes. The disability parking permit application is structured as a care plan action item — with eligibility criteria, the medical certificate task, and patient instruction included — so it is completed at the visit rather than deferred.
Caredevo is designed with a local-first mindset. Identifiable patient data is not used to train models, and you remain in control of what you save, export, or paste into your EMR.
Yes. Caredevo is EMR-agnostic. You can copy and paste structured health assessment care plan content into Best Practice, MedicalDirector, or any other system without waiting for deep integration.