Table 3 Palliative care consult documentation template (entered into eHR)

Hospital Name [AUTOPOPULATE, if possible]

Date of consult: [AUTOPOPULATE, if possible]

Patient Name/DOB/Gender/Race/MR# [AUTOPOPULATE, if possible]

Referral Source/Provider: [AUTOPOPULATE, if possible – if considered an “order”]

Primary problem/focus of consult: [If possible, havedrop-down listwith these options:

• Symptom Management

• Support/Coping

• Goals of Care/Advance Care Planning

• Interdisciplinary referral(s)

• Local Resources / Community Care Medical / Other Support Communication

• Hospice / Home Services

• Other]

Secondary problem/focus of consult: [If possible, havedrop-down listwith these options:

• Symptom Management

• Support/Coping

• Goals of Care/Advance Care Planning

• Interdisciplinary referral(s)

• Local Resources / Community Care Medical / Other Support Communication

• Hospice / Home Services

• Other]

History of Present Illness:

Past Medical/Surgical History: [AUTOPOPULATE, if possible]

Medications Review and Allergies: [AUTOPOPULATE, if possible]

Physical ROS/Cognition/Functional status:

Social History/Assessment:

Support Systems/Family concerns:

Spirituality/Beliefs:

Physical Exam-Limited: [AUTOPOPULATE Vital signs, Weight, Inputs/Outputs (including bowel movements) if possible]

Lab/Diagnostic studies/Records Review Highlights: [DO NOT AUTOPOPULATE]

Palliative Performance Scale: [if possible, have table below displayedANDdrop-down with choices:

• 100% = Ambulation: Full; Activity & Evidence of Disease: Normal activity & work, No evidence of disease; Self-Care: Full; Intake: Normal; Conscious Level: Full

• 90% = Ambulation: Full; Activity & Evidence of Disease: Normal activity & work, Some evidence of disease; Self-Care: Full; Intake: Normal; Conscious Level: Full

• 80% = Ambulation: Full; Activity & Evidence of Disease: Normal activity with Effort, Some evidence of disease; Self-Care: Full; Intake: Normal or reduced; Conscious Level: Full

• 70% = Ambulation: Reduced; Activity & Evidence of Disease: Unable Normal Job/Work, Significant disease; Self-Care: Full; Intake: Normal or reduced; Conscious Level: Full

• 60% = Ambulation: Reduced; Activity & Evidence of Disease: Unable hobby/house work, Significant disease; Self-Care: Occasional assistance necessary; Intake: Normal or reduced; Conscious Level: Full or Confusion

• 50% = Ambulation: Mainly Sit/Lie; Activity & Evidence of Disease: Unable to do any work, Extensive disease; Self-Care: Considerable assistance required; Intake: Normal or reduced; Conscious Level: Full or Confusion

• 40% = Ambulation: Mainly in Bed; Activity & Evidence of Disease: Unable to do most activity, Extensive disease; Self-Care: Mainly assistance; Intake: Normal or reduced; Conscious Level: Full or Drowsy +/− Confusion

• 30% = Ambulation: Totally Bed Bound; Activity & Evidence of Disease: Unable to do any activity, Extensive disease; Self-Care: Total Care; Intake: Normal or reduced; Conscious Level: Full or Drowsy +/− Confusion

• 20% = Ambulation: Totally Bed Bound; Activity & Evidence of Disease: Unable to do any activity, Extensive disease; Self-Care: Total Care; Intake: Minimal to sips; Conscious Level: Full or Drowsy +/− Confusion

• 10% = Ambulation: Totally Bed Bound; Activity & Evidence of Disease: Unable to do any activity, Extensive disease; Self-Care: Total Care; Intake: Mouth care only; Conscious Level: Drowsy or Coma +/− Confusion

• 0% = Death

Goals of Care / Advance Care Planning Assessment:

Global Assessment Statement:

Recommendations/Plan:

A. Symptom Management

B. Support / Coping

C. Goals of Care / Advance Care Planning (inc. AD, Proxy, DNR, POLST, etc.)

D. Interdisciplinary Referrals (PT, OT, Spiritual, Counselor, Social Work, etc.)

E. Local Resources / Community Care Medical / Other Support / Communication

F. Hospice / Home Services

G. Other

Transition/Discharge Plans (if known):