Palliative Outpatient initial visit

OVERALL_INSTRUCTIONS

Chief Complaint

[Symptom management, goals of care, disposition planning, or other reason for consultation]

Template

Date: [Insert Date] Referring Provider: [Insert Referring Provider Name] IDENTIFICATION: [Insert Age]-year-old [Insert Gender]. PALLIATIVE DIAGNOSIS: [Insert Palliative Diagnosis] REASON FOR CONSULTATION: [Insert Reason for Consultation] DISEASE COURSE: [Describe the course of the primary palliative illness, treatments exhausted, current treatment plan, or transition to supportive/comfort care.] HISTORY OF PRESENTING ILLNESS AND SYMPTOM REVIEW: [Insert HPI and symptom review of most recent issues and issues pertinent to management today] PAST MEDICAL HISTORY: [Insert Past Medical History] HOME MEDICATIONS: [Insert Home Medications] ALLERGIES: [Insert Allergies] SOCIAL HISTORY: [Insert Social History] PHYSICAL EXAMINATION: [Insert Physical Examination] VITALS: [Insert Vitals] PERTINENT LABS: [Insert Pertinent Labs] PERTINENT IMAGING: [Insert Pertinent Imaging] GOALS OF CARE DISCUSSION: [Insert Goals of Care Discussion] PALLIATIVE CARE DOCUMENTATION: Palliative Care Benefits (Plan P): [Yes or No] Representation Agreement, Advance Directive or other Advance Care Planning document: [Yes or No] MOST Designation: [Full code, DNR C1, DNR M3, DNR M2, DNR M1] Substitute Decision Maker: [Insert Substitute Decision Maker] Community DNR: [Yes or No] ASSESSMENT AND PLAN: [Insert Assessment and Plan] FOLLOW UP: [Insert Follow Up Plan] Sincerely, [Insert Consulting Physician Name and Contact Information]