9 Brief Consultation Outline

Name/Service, Attending, Patient Name/#, Requesting/Reason/Date

Palliative Care Assessment:

• Introduction:
  • Age, Gender, Location, Adm Date, 1˚ Disease, CC
• Background:
  • Social (Family, Work, Live)
  • Psych (prior dx, coping, substances)
  • Spirit (religion, existential)
• PMH:
  • Med, Surg, Allergies, incoming Meds
• 1˚Disease:
  • Dx, Rx, current Status, Adv Directive, Code Status
• Symptoms:
  • Describe, Assess
    • Pain
    • Fatigue
    • Sedation, Drowsiness
    • Sleep Disturbance
    • Appetite, Dysphagia, Wt Loss
    • N/V, Constipation, Diarrhea
    • Incontinence
    • Itch
    • Depression, Anxiety
    • Hallucination, Myoclonus, Seizure
• Exam:
  • VS
  • Cachexia, Wt Loss, Overt Manifestation of 1˚ Disease
  • Cognition/Delerium
  • Mouth, Nodes, Chest, Heart, Abd, Skin, Extremities, Neuro Describe Painful Locations
• Other Info:
  • Relevant Labs, Imaging, Consults
• Impressions:
  • Palliative Care Diagnoses
• Assessment:
  • Analysis of sx and/or perspective on communication/decision-making
  • Recommend/Plan