Document
Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Elderly Care Medicine
AI Voice-Driven Reporting for elderly care physicians
Hysio organises your admission, home visit, ward round or care planning conversation: source, functioning, examination and management plan kept apart. The medical assessment stays with you.
Spoken care information from your care encounter
Elderly care medicine
A structured report in your professional terminology
From care encounter to report
You work. Hysio documents.
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
AI assistants
Suited to your work.
- Hysio Elderly Care Medicine Admission Intake
- Hysio Elderly Care Medicine Home Visit
- Hysio Elderly Care Medicine Ward Round
- Hysio Elderly Care Medicine Advance Care Planning
- Hysio Elderly Care Medicine SOAP Note
You stay in control of what gets saved.
In your workday
How Hysio fits into your workday
More attention for the conversation, less typing afterwards.
-
You document the conversation
State relevant information, your own findings and agreed actions aloud so you can find them in your report.
-
Hysio creates your report
The information appears under the headings of your chosen report format, so you can review each section.
-
You review and copy the report
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
Try it yourself
Experience what Hysio can mean for your work.
Try Hysio free for 14 days or schedule a personal demo.
- No credit card needed
- Cancel any month
- GDPR-compliant, data hosted in the EU
Profession
Hysio Elderly Care Medicine
For your team
Share with a colleague
Quick answer Admission, ward round and advance care planning 50 questions with cited sources
Quick answer
Documentation for elderly care medicine
A profession-specific structure for complex care of older people: functioning, frailty and context, with source, findings, examination and management plan under their own headings.
Read how Hysio comes along to an admission, a home visit, a ward round or a conversation about advance care planning. Hysio records what was said, seen and decided, in the documentation formats of the specialty.
- What does Hysio do at an admission or ward round?
- Hysio listens to what you say at an admission to the nursing home and turns it into an admission intake. That way of working is called voice-driven reporting, or AI documentation. There are five documentation formats: Elderly Care Medicine Admission Intake, Elderly Care Medicine Home Visit, Elderly Care Medicine Ward Round, Elderly Care Medicine Advance Care Planning and Elderly Care Medicine SOAP Note. [2] [3] [4] [5] [6]
- What does Hysio include from informal carers and care staff?
- What the older person, the informal carer and the care staff say stays separate from your own observation. Hysio only includes what someone actually said. [1] [12]
- Who decides on the text?
- You, as the elderly care physician. You review the report, including the collateral history, and decide what goes into the record. [1] [10]
- Profile code 041
- Documentation formats 5 profession-specific documentation formats: Hysio Elderly Care Medicine Admission Intake, Hysio Elderly Care Medicine Home Visit, Hysio Elderly Care Medicine Ward Round, Hysio Elderly Care Medicine Advance Care Planning, Hysio Elderly Care Medicine SOAP Note.
- Source focus frailty, functioning and the context of the older person
- Record boundary report with separate sources, judgement with the physician
Voice-driven reporting for admissions, ward rounds and home visits
Which documentation format fits a geriatric history? #
The format follows the contact, not the topic. A comprehensive history at admission belongs in the Elderly Care Medicine Admission Intake, where the history and the collateral history each get their own heading alongside past medical history and functioning. If you take the same history with someone at home, the Home Visit fits; if it is a short round on the ward, the Ward Round. In all three, the request for help goes under reason for contact, with the source alongside it. [2] [3] [4] [5] [6] [1] [12]
How do you organise polypharmacy and information from informal carers in the record? #
Keep them apart. The current medication is a personal detail that belongs to the patient and not to this one contact. What someone close to the patient says about taking the medication, side effects or their own burden belongs in the history and collateral history, with the relationship noted. Put both under fixed headings, so that a colleague can later see who supplied what and when. You record a change in the medication under the management plan, because that is your decision. [2] [1] [11]
How do you record cognitive observations in the record? #
Separate observation and judgement. What the care staff report about restlessness or disorientation you record as a source report, your own observation goes under the examination findings and a stated conclusion stands apart. You copy a score literally with instrument, value, date and assessor. Then choose deliberately where the text goes: the medical treatment record carries the medical line, the care and living plan the agreements for daily care. [11] [1] [2]
How do you handle what an informal carer tells you with care? #
From someone close to the patient, record only what is needed for this care. Name and relationship may be included, because without a source role the report is not accurate; details about the health or situation of that person themselves do not belong in the patient's record. Who was present, who is the representative and what consent was given for are three separate facts, and you record them separately too. When in doubt, follow the rules of your institution. [9] [12] [1]
What does voice-driven reporting cost for a team in a nursing home? #
Hysio costs €20 per person per month for Starter, €40 for Pro and €80 for Unlimited, each excluding VAT. With a yearly subscription, you pay for ten months and get twelve. The difference lies in the number of sessions per month, not in what a documentation format may record: the boundaries around functioning, examination and management plan are the same in every plan. The current terms are on the Hysio pricing page. [7] [8]
When is your own template enough instead of Hysio? #
Your own template in your record system works well for short, uniform contacts in which you are typing anyway. Check whether the template keeps source roles identifiable when the source is spoken and several people contribute: the patient, a daughter and care staff. Then compare on that one point. Can you still see in the end result who said what and when? If that holds up, your own route is good enough. [1] [11] [12]
How do you check the medication list against the source? #
Read back the drug, strength, dose and frequency against the source they come from, and not against your memory. A name that looks complete in the text but was only half pronounced in the dictation should remain incomplete until you fill it in. If a dose is missing, leave that gap visible. With polypharmacy, a list that has been filled in is more dangerous than a list that is honestly incomplete. [1] [12] [10]
How do you keep your attention on the patient while taking the history? #
Conduct the conversation as you always do. With someone who has cognitive complaints, it helps not to type while taking the history, but to let the contact run its course and only afterwards dictate what you saw and discussed. Ask someone close to the patient specifically for additions instead of letting them take over the conversation. Afterwards, read back whether the text still reflects how the contact really went. [1] [2] [11]
What makes Hysio different for information from informal carers? #
The difference lies in attribution. In free dictation, it must remain clear which words come from the patient, the daughter and the care worker. The elderly care medicine documentation formats set participants and source roles apart and keep the collateral history separate from what the patient says themselves. What the source does not support stays empty instead of being plausibly filled in. Weighing that information remains your work. [1] [2] [11]
How do you start with a new documentation format in your team? #
Start small and measurable. Take one type of contact, for example the ward round on your own ward, and for two weeks put side by side what you would have written yourself about walking, transfers and falls and what the organised text makes of it. Agree who reads it through before anything goes into the record. If it works there, you extend to the home visit and the admission. [8] [9] [1]
Documentation formats for elderly care physicians
Which format fits a broad first admission to the nursing home? #
For a broad first admission, this format fits. It keeps reason for contact, participants and source roles, past medical history, history and collateral history, functioning and context, physical examination and additional investigations apart, with conclusion and management plan as their own headings. As a result, frailty comes back as a description of functioning and not as a standalone label. With voice-driven reporting, anything the source does not mention gets the fixed line that it has not been documented. The conclusion remains yours. [2] [1] [12]
Do you use a separate documentation format for a home visit? #
For a visit at home, yes. The home visit report has its own heading for functioning and home context, where the stairs, the thresholds, the management of medication and the burden on the informal carer belong. The patient's report, the collateral history, the home care report and your own observations stay separate. No summarising advice is added that you have not stated. Reason, finding and the agreed follow-up each stand under their own heading. [3] [1] [12]
Is there a separate format for a short ward round? #
For a short contact on the ward during a round, this format fits best. It starts with the current situation and the report supplied by the care staff, followed by your observations, additional investigations, conclusion and management plan. No fixed national heading structure is imposed here, because the format follows what you actually saw and agreed on that round. Hysio does not add urgency, a new diagnosis or a judgement about the medication. [4] [1] [12]
When do you use the format for advance care planning? #
Only when the conversation is truly about care planning and the patient or an explicit representative takes part. The format sets apart the patient's perspective, the input of the representative and those close to the patient, values, goals and concerns, the information and questions discussed, the wishes, preferences and limits, and the decision status with open points. What is not yet a decision does not become one. Hysio decides nothing about decision-making capacity or representation. [5] [1] [12]
What do you use the SOAP note for with a resident? #
That is what this format is intended for: the short, regular follow-up contact with a resident. Subjective carries the patient's report and the collateral history from the care staff, Objective your own examination, Assessment the working hypothesis you stated and Plan the management plan discussed. SOAP here is not borrowed general practice language but an ordering the profession itself uses, alongside the six domains: somatic, functional, social, mobility, psychological and communicative. [6] [1] [12]
Which documentation format fits when mobility is central? #
Choose by the contact, not by the topic. Mobility can come up in any format: as functioning and context at admission, as home context at the home visit, as the current situation at the ward round and as an objective finding in the SOAP note. So the question is which contact you had and who was there. Only then does the content of the source determine how full a heading becomes. [1] [2] [12]
When do you choose an intake and when a follow-up report? #
You choose an intake when you rebuild the whole picture: at admission, when taking over medical responsibility or at a thorough reassessment. For a follow-up contact that is too heavy. There, what counts is what has changed since last time, and the rest stays where it already was. A planned evaluation of the care plan is a moment of its own and does not turn a follow-up contact into a new intake. [1] [2] [12]
Which details belong with a result and a change in medication? #
A result comes with which investigation it was, when it was done, who requested it and what literally came out of it. If that leads to a change in the medication, you record the drug, what changes and that you decided it, and that goes under the management plan. The result itself stays under additional investigations. Procedures that belong to another report type, such as a separate medication review, stay out of it. [1] [2] [12]
Which source information about cognition belongs in a handover? #
What the recipient needs to be able to act tonight or tomorrow: the current situation, what recently changed, which agreements are in place about treatment and management, and who the contact person or representative is. You copy a cognitive diagnosis or score as it stands in the record, with the date. A handover is a report type of its own; a ward round or intake report does not turn itself into a letter. [1] [2] [12]
How do you separate information from informal carers from other sources? #
Label each line with who was speaking. The patient, someone close to them, the care staff, the general practitioner and you yourself are five different sources, and the format keeps them apart under participants and source roles. A daughter who comes along is not thereby a representative; that role only appears if the source names it. You record presence, representation and consent separately, because they are three different facts. [1] [2] [12]
Recording informal care, medication and mobility
How do you describe information from informal carers in the history? #
Give the collateral history its own paragraph and add the relationship: daughter, partner, carer. What the patient says themselves stays in their own words. If the picture differs, you put both accounts side by side instead of making one story of them. Only include what was discussed in this contact; what you know from an earlier occasion belongs in the past medical history and not in today's history. [1] [12]
Who gave information about mobility? #
Every statement needs its origin. If, by their own account, the patient still walks with a rollator, the care staff report two falls and the physiotherapist saw a laboured transfer, those are three facts with three sources and not one conclusion. Keep your own observation apart from what you have heard. Without that separation, a colleague will not be able to check later what the management plan rested on. [1] [12]
How do you note a score with its time of measurement? #
Copy a score as it was supplied: name of the instrument, value, date and who administered it. Think of a Barthel Index, a Katz scale or an observation scale for delirium. Do not calculate anything, do not round anything and do not test a value against a cut-off; that interpretation is your work and you write it in your own words. If the date is missing, the score stays incomplete until you add it. [1] [12]
How do you link polypharmacy to the result? #
Put the result under additional investigations, with investigation, date and requester, and put what you do with it under the management plan. A kidney function that calls for a dose adjustment only becomes an adjustment when you state it; until then it is a result. That way, with voice-driven reporting too, it stays visible which part is measurement and which part is judgement, even when a colleague reads the record months later. [1] [12]
Can Hysio assess cognition from imaging? #
No. Images are not read and a report is not reinterpreted. A radiology report comes across as it was supplied, with date and origin, and stays under additional investigations. What that finding means for this patient's cognitive picture is something you state; only then does it go into the conclusion. If the result does not arrive, the text states that no additional investigations have been documented. [11] [10] [12]
Which technical term fits information from informal carers? #
Use the terms of your own profession. Collateral history, informal carer, contact person, legal representative and mentor (in the Dutch legal sense) all mean something different and are not synonyms. Avoid language that belongs to another profession, such as regiebehandelaar (coordinating practitioner) or ondersteuningsplan (support plan); here the terms are hoofdbehandelaar (lead practitioner), medebehandelaar (co-practitioner) and consulent (consulting practitioner). Agree within your specialty group which abbreviations you use and write them out in full the first time, so that the care staff also read the report as you intended. [1] [12]
How do you note what a relative says about mobility? #
Write down who said it, what they saw and when: the son reports that since last week his mother can no longer get up the stairs. That is an observation by someone close to the patient and not a finding of yours, and the two stay apart. If that person or a referrer then wants to receive information, you first check purpose, role and consent. What you share, you record. [1] [12]
What does the team need to know about the geriatric history? #
For a meeting, what counts most is who brings in which domain. The care staff describe daily functioning, the physiotherapist mobility, the psychologist behaviour and you the medical line. Write functioning in words that are usable at the table and keep treatment plan, care plan and care and living plan apart, because those are three documents with three owners. Finally, record who picks up which point and when it comes back. [1] [2] [12]
Which case shows polypharmacy? #
Take a resident who is being checked after a fall. The report states what the care staff saw, what you found on examination, which drugs are on the list and that you are reviewing the sleep medication with the pharmacist. What is not yet a decision remains an intention. Invent no diagnosis, no cause and no outcome, because a case is only instructive when it is accurate. [1] [12] [2]
How do you make a handover about cognition? #
First determine the purpose and the recipient, because that determines what may go in. A covering doctor at the weekend needs different information from the admitting hospital ward. Include what is on record, with source and date, and leave out the rest. A reader must be able to trace every detail in the record; what is only in your head does not belong in a handover. [11] [9] [12]
Mental capacity, emergencies and privacy: the boundaries
Does Hysio make a cognitive diagnosis itself? #
No. A delirium, a cognitive disorder or a suspicion of one only appears in the text when you have stated it or when it is demonstrably in the supplied source. Hysio organises what was said and seen; the interpretation stays with the specialist in elderly care medicine. A working hypothesis or differential diagnosis is not added either. If there is no conclusion in the source, the text states that no conclusion was stated. [10] [1] [12]
Who checks the collateral history before saving? #
You. As the treating specialist in elderly care medicine, you decide what goes into the record and in what form. Before saving, read back whether the role of the person close to the patient is right, whether the quote is as it was meant and whether nothing has been merged that should have stayed separate. Hysio does not take over that assessment and does not deliver text that approves itself. Signing off and responsibility for the record stay with you. [1] [10] [12]
What do you do if mobility information is missing? #
Leave the gap. If nothing was discussed about walking, transfers or fall risk, the fixed line appears there that it is not documented in the supplied source. Copying a value from a previous contact seems helpful, but makes the report incorrect because the date no longer matches. If you still want to know, ask about it and add it with the new point in time noted. [1] [10] [12]
Can Hysio help in an acute situation? #
In an acute situation, you act first. Hysio does not weigh urgency, does not set priorities and does not assess whether someone needs to be seen urgently; that judgement is medical and stays with you. Afterwards the ordering does help: what you found, what you did and what you agreed, with time and source noted. With voice-driven admin, even under time pressure, you can read back what your decision rested on. [10] [9] [12]
Who may receive information about polypharmacy? #
Only those who have a role in the treatment or have consent for it. The pharmacist and the general practitioner usually fall within the treatment relationship; a family member does not automatically, not even when they are the contact person. A legal representative has a position of their own, and that must be evident from the source and not from presence. Record who may receive what and for what purpose, and then share no more than that. [9] [12] [1]
Does Hysio make a treatment plan itself? #
No. The treatment plan is your work: you formulate the main objective, the problem analysis, the sub-goals and the prioritisation, together with the patient and the team. Hysio puts the management plan you stated under the right heading and leaves the rest empty. Nor is a proposal for medication, day activities or investigations added. Treatment plan, care plan and care and living plan also remain three different documents. [10] [11] [12]
How do you note uncertainty in the report? #
Keep the doubt in the text. If the daughter says her father probably skips his tablets, the word probably stays, because a report may never sound more certain than its source. Record what you do not yet know as an open point, with whom you will check it and when. An honest report with an open question is more useful than a polished report that suggests certainty. [1] [12] [10]
How do you handle sources that contradict each other about mobility? #
Keep both accounts. If the patient reports that walking is going well while the night shift reports two falls, that is not an error in the text but a difference you want to see. Put them side by side with their origin and date, and only then write down your own judgement. Choosing a middle ground or smoothing over the difference later costs you exactly the information your management plan rested on. [1] [12]
How do you note medication and geriatric history? #
Literally. You copy drug names, strengths, doses, units and measured values as they were supplied, without converting, rounding or adding. With polypharmacy, a seemingly small correction is a real risk. If something does not add up or a unit is missing, it stays as incomplete instead of being resolved automatically. You then assess what the value means for this patient. [1] [12] [10]
How do you check the report before saving? #
Read it back against the source and not against your memory of the conversation. Check the medication lines for drug, dose and date, see whether the source roles are right and whether the conclusion is really yours. Correct what deviates before you save, because after that the text is part of the record. If you approve, you also stand behind what is there, including the lines you skipped. [1] [9] [10] [12]
Introducing Hysio in the nursing home team
How do you prepare a handover about polypharmacy? #
Agree with your specialty group what a covering doctor needs at a minimum: the current medication, the changes of the past few days, the agreements about treatment and management, and who the contact person is. Put that in a fixed order, so that no one has to search. Also decide who reads the text through before the shift changes. A handover remains a report type of its own and is not a copy of the ward round report. [11] [9] [12] [2]
Which team agreement do you need for cognition? #
Three agreements are usually enough. Which headings you use, which terms and abbreviations you share, and who approves a report before it goes into the record. Also agree where the text lands: the medical line in the medical treatment record, the agreements for daily care in the care and living plan. Without that choice, the same observation ends up in the record twice, and slightly differently in two places. [1] [2] [11]
How do you first test voice-driven reporting on one ward? #
Take one ward and one type of contact, for example the conversation with the family after admission. Run it for fourteen days, collect the corrections you make and look at where they come from: the source, the ordering or your own way of dictating. Discuss those first weeks of voice-driven reporting with two colleagues. Only when the collateral history comes back recognisably and correctly do you extend to other contacts. [8] [9] [1]
How do you adapt a report on mobility to local agreements? #
Put the format next to the headings your institution uses and see where they differ. Usually that is a matter of order and naming, not of content. Keep the separation between source, finding and management plan intact, because that makes the report traceable. Also check who has which authorisation, because a text that no one is allowed to save is not a report. Record the choice made in writing. [11] [1] [12]
How do you record a collateral history in dementia? #
For each piece of information, say who it comes from: the client, the informal carer or the primary carer on the ward. Hysio keeps those sources apart in the report. In a family meeting, the agreements stay separate from what the family said. You decide what goes into the record. [1] [12] [2]
How do you measure whether voice-driven reporting pays off in the nursing home? #
Measure your own practice instead of adopting a promise. For one week, time per type of contact how long you spend from conversation to saved report, including reading through and correcting. Compare that with a comparable week before. Count the corrections too, because a text you have to adjust three times gains you nothing. A gain you have not measured yourself is no gain. [1] [11] [8]
Which conditions apply to the Hysio trial period? #
The free trial lasts fourteen days, you do not need a credit card for it and you can cancel monthly; the current terms are on the pricing page. Use those two weeks on real contacts and not on an invented case, because only then do you see whether the collateral history and the observations about functioning are accurate. Do work within your institution's agreements on the processing of patient data. [8] [7] [9]
Where can you find rates, privacy and terms as an elderly care physician? #
Spread your questions across four places. The pricing page gives the rates and the free trial, the privacy policy describes the processing of data, the legal information carries the terms and the disclaimer sets out what Hysio does not do. What someone close to the patient may hear and what you record in the record also follow from your professional standards and your institution's policy. Those two lines do not replace each other. [7] [9] [10]
How do you record your own terminology around mobility? #
Make one list per specialty group and keep it short. Include which abbreviations you use for transfers, walking aids and fall risk, and write them out in full the first time they are used. Also include which words you deliberately do not use because they belong to another profession. Share the list with the care staff, because they read along. If something changes, update the list before the reports start to diverge. [1] [11] [12]
Where do you start with a case around the geriatric history? #
First break the case down into contacts and sources: who spoke when, and what was supplied? Then go through the domains, from somatic and functional to social, mobility, psychological and communicative. That way, even with multimorbidity, it stays visible where each problem belongs. Write the conclusion and management plan last, in one go, and do not let the text draw connections you have not stated. [1] [12] [2] [10]
Sources
- 1 Hysio: Beroepsprofiel de ouderengeneeskunde (interne Hysio-documentatie) Document date: 2026-08-09 Accessed on 2026-08-31
- 2 Hysio: Hysio Ouderengeneeskundige Opname-intake (interne Hysio-documentatie) Document date: 25 augustus 2026 Accessed on 2026-08-31
- 3 Hysio: Hysio Ouderengeneeskundig Huisbezoek (interne Hysio-documentatie) Document date: 25 augustus 2026 Accessed on 2026-08-31
- 4 Hysio: Hysio Ouderengeneeskundige Visite (interne Hysio-documentatie) Document date: 25 augustus 2026 Accessed on 2026-08-31
- 5 Hysio: Hysio Ouderengeneeskundige Proactieve Zorgplanning (interne Hysio-documentatie) Document date: 25 augustus 2026 Accessed on 2026-08-31
- 6 Hysio: Hysio Ouderengeneeskundig SOEP-Verslag (interne Hysio-documentatie) Document date: 26 augustus 2026 Accessed on 2026-08-31
- 7 Hysio: Actuele Hysio-prijzen (interne Hysio-documentatie) Document date: 2026-08-26 Accessed on 2026-08-31
- 8 Hysio: Actuele proefperiode (interne Hysio-documentatie) Document date: 2026-08-31 Accessed on 2026-08-31
- 9 Hysio: Hysio Privacyverklaring (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 10 Hysio: Hysio Disclaimer (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 11 Hysio: Hysio en medische dossiersystemen (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 12 Overheid (wetten.overheid.nl): Wet op de beroepen in de individuele gezondheidszorg (Wet BIG) Document date: 2026-08-04 Accessed on 2026-08-04
- 13 Verenso: Nota Medische Verslaglegging. Dossiervoering door de specialist ouderengeneeskunde (met drie samenvattingsfolders) Document date: 2026-08-04 Accessed on 2026-08-04
- 14 Capaciteitsorgaan: Capaciteitsplan 2024-2027, Deelrapport 5, Specialist Ouderengeneeskunde Document date: 2026-08-04 Accessed on 2026-08-04
- 15 Zorginstituut Nederland: Kwaliteitskader Verpleeghuiszorg Document date: 2026-08-26 Accessed on 2026-08-26
- 16 Richtlijnendatabase, initiatief NVKG: Comprehensive Geriatric Assessment (CGA) Document date: 2026-08-04 Accessed on 2026-08-04
- 17 Richtlijnendatabase, initiatief NVKG: Delier bij volwassenen en ouderen Document date: 2026-08-04 Accessed on 2026-08-04
- 18 Richtlijnendatabase, initiatief Cluster Algemene geriatrie/ouderengeneeskunde: Identificatie van kwetsbaarheid bij ouderen (module bij de richtlijn Comprehensive Geriatric Assessment) Document date: 2026-08-04 Accessed on 2026-08-04
Hysio creates the report. You remain responsible for what you save in the record.