HMC PALLIATIVE CARE INPATIENT CONSULT NOTE TEMPLATE INSTRUCTIONS
REASON FOR CONSULT
This section is required for billing, please complete all blank sections. The referring provider
HAS to be the ATTENDING of the primary team.
OUTPATIENT PROVIDERS
This serves as a reminder to contact all of the outpatient providers for the patient early and often and ask them if they want to participate in any care conferences. Please cc relevant inpatient and outpatient providers on your notes.
ID/CC/HPI
An ID/CC is required for every billable note. The HPI in palliative care can be a brief paragraph and should highlight the key diagnoses, events that led the hospitalization and any major setbacks or complications during the hospital stay.
PALLIATIVE CARE DISCUSSION HELD TODAY
This is where the majority of the information gathered from the initial consult is placed. We also recommend using this section for follow up visits where a lot of information is gathered or a large family meeting is held. Sometimes it may seem that information doesn’t always fit neatly in these categories, but it is meant to focus on the key important palliative care features of the history and help create a narrative of the patient’s story. If you have something you want to add and it doesn’t seem to go in any category, often the “understanding” section is a good place to put this. Alternatively, if you do not want to use this format at all, for example if the structure of the meeting was not designed like an initial consult (this is commonly the case with follow up family meetings), you can delete this part and write in paragraph form. If there is a section that you don’t have information for, delete it.
Participants: List those all those in attendance, with names when possible including attendings, residents, students, nurses, family, friends etc.
Voice: If the patient spoke for their self, list the patient, if they were unable explain why and who spoke for them.
Background/social history: Use this section to detail where the patient is from, where they grew up, who the key people in their life are, education, employment history, how they spend their time etc.. This is also a good place to describe how they were managing their ADLs/IADLs if relevant.
Last updated 8/20/15

Understanding/perspective of illness: This is a summary of how the patient/family describes the illness/prognosis, their perspective on how it has impacted their life, their understanding of the treatment options and plan etc. Try to use any direct phrases or quotes when able.
Hopes and what brings life meaning or purpose: This includes personal hopes or goals both medically and otherwise. What keeps them going, do they have a “bucket list.” What do they value most, what is most important to them, how do they want to spend their time etc.
Acceptable quality of life: What does the person need to be able to do in order to make the medical care worth it to endure? (Keeping in mind that some patients may need time to adjust to a new level of function). Also includes how much a person is willing to go through for a chance at achieving this goal.
Fears/concerns/worries: What are they worried about, what concerns do they have, are their parts of their care with which they are dissatisfied (communication etc.).
Strengths/role of spirituality/faith/religion: Asking a patient where they get strength to endure their illness can sometimes easily open the door to talk about religion or spirituality. If they mention other strengths (family, friends, personal will etc.) but not spirituality, you can say
“some patients find strength in spirituality or a formal religion, is that something that has been helpful for you?” Document any findings here.
Cultural preferences: Inquire if there are any particular rituals, beliefs, or practices they follow that we should be aware of or help them incorporate in their care.
Communication preferences: Do they want all the information whether good or bad, do they want information as it comes, do they prefer information be given to a family member instead of themselves, are there certain people with whom they do not want their care discussed etc.
Past experience with serious illness/hospice: May include their own illness, or others close to them. Do they have experience with hospice, ICUs, dialysis, dementia, cancer, stroke CPR, ventilators etc.
Caregiver concerns: Ask how the caregiver is doing, are there ways we can better support them or specific concerns they have, sometimes financial concerns can arise here. Discuss self care when applicable.
Other: Anything else that came up in the discussion that does not fit elsewhere.
Last updated 8/20/15

PHYSICAL EXAM
Every patient must have a physical exam for billing to document that the patient was seen, even if the main visit was a family meeting. The physical exam in palliative care can be brief and directed (unless you are seeing the patient primarily for pain/symptom management, then a detailed exam that is tailored to their pain or symptom complaint should be done).
IMPRESSION
The impression section in palliative care is more expansive then the standard progress note that reads 74 y/o M w/ h/o ABC admitted for XYZ. In palliative care, this is your opportunity to consolidate the information you gathered above and make a statement about how much the patient/family understand about their illness, what you perceive to be their primary goals (both for medical care, but also in the broader sense), and whether these goals seem attainable with the current plan of care. You may also make statements here about barriers in their care (i.e. cultural differences, miscommunication etc.). This way your recommendations that follow are concise and reflect your impression.
Here is an example:
“Mr. Jones has a good understanding that his cancer is metastatic and that although there are a few palliative chemotherapy options available, these would carry substantial physical burdens.
Mr. Jones prioritizes comfort over longevity or independence, and his main goal is to return home, spend time with his wife of 50 years and focus on quality of life. Currently his pain is severe and he fears that without improvement in pain control, he will not be able to manage at home and is hopeful this will be improved prior to discharge home with hospice.”
Goals of Care: Restate a simplified version of the goals, for example “patient prioritizes comfort over longevity and independence,” “time with family, or “return to prior level of independence” etc.
Estimated Prognosis: Avoid specific numbers, but rather use general estimates such as “hrs to days,” “days to weeks,” “weeks to months,” “months,” or “months to years.” This is also how likely you think the patient will achieve the stated goals, “good chance at meeting above goals” etc. Also, if we think a patient is hospice eligible, we should state it here; “based on the patient’s metastatic lung cancer, anticipate the patient will not live longer than 6 months.” If oncology or another specialty has stated a prognosis in another note, you can repeat it here and reference that note. If you are having trouble estimating time, talk with your attending.
Palliative Performance Scale (Now): Use the chart to determine.
Palliative Performance Scale (Best in recent weeks): Use the chart to determine, this gives a sense about how much it has changed since admission and potentially for returning to the PPS.
Last updated 8/20/15

RECOMMENDATIONS
The recommendations are organized according to the 8 domains of palliative care (Process of
Care, Physical, Psychological, Social, Spiritual, Cultural, Ethical/legal, Imminently Dying) based on the National Consensus Project for Quality Palliative Care. On your initial consult note (or the first extensive note you write for a patient) ALL domains should be addressed even if you say “No current recommendations.”
Pain and Physical Symptoms
--If recommending narcotics, describe reasoning, document calculations for conversions and document plan for adverse side effects.
Psychological/Social/Spiritual/Existential/Cultural Concerns
--For delirium, discuss risks, describe prevention strategies and medical/non-medical interventions
--Good place to describe communication preferences, how decisions are made, caregiver needs, social support, unique relationships (for example if there are complicated family dynamics such as certain family members who are not allowed to visit etc.), or barriers to care such as finances, transportation, equipment needs etc.
--Include details about interpreter use/cultural mediators.
--Include any particular cultural practices, rituals and preferences, especially around communication, decision making and end of life/dying.
--If patient has a specific religious practice/spiritual practice or preferences, list them here.
Include concerns about existential suffering, meaning, purpose, afterlife, guilt/regrets etc.
Include if you think the patient will benefit, or is already being followed by spiritual care
Ethical/Legal/Surrogate/Code Status/Advance Directives/POLST
1) Surrogate decision maker: should be documented on EVERY note, delete parts that are not relevant (i.e. if there is no guardian than delete this). This is where DPOAHC information is noted, please list the name, relationship to the patient, contact information, and where the paperwork is located, if you completed this with the patient, note the date and that a copy was placed in the chart. The most reliable source of LNOK information is usually from the MSW notes that are titled “Social Work Assessment, please make sure to add any changes or make necessary edits. Sometimes LNOK is under the ED MSW notes. Include phone numbers when available. Put other important contact information such as a case manager etc. in the “other” section.
2) Code Status: Is included in EVERY note. If you did not discuss it, you can say “not addressed today, will explore in future visits.” If you know the patients code status document it and the reasoning or source of information. If appropriate you can add qualifiers, for example: “patient is currently full code, however has a low chance of survival to discharge if suffers a cardiac
Last updated 8/20/15

arrest, if patient becomes unstable overnight recommend the primary team talk with the
patient’s family about considering a DNAR order and not escalating medical care.”
3) POLST: if you completed a POLST form, or the patient was admitted with one, then fill out the sections here, note when the form was prepared and by whom. If there are additional comments on the POLST, note these in the “OTHER” section of the POLST section. Please complete a POLST on all patients when applicable. You can also comment if you want the primary team to complete the form prior to discharge if our team is unable.
4) Other: This may include information about advance directives, concerns about decisional capacity or ethical conflicts.
Discharge Planning
This is where to put information about hospice referrals, outpatient follow up (for example for our outpatient palliative care clinic), if a patient is imminently dying and you do not think they should be discharged etc.
Last updated 8/20/15