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Note Type:
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CC/HPI:
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ROS:
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If Other, please specify:
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Medical Problems:
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CV
• • •
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Pulm:
• • •
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Gastro:
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Endo:
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Skin:
• • •
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Renal/ FU:
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M/S:
• • •
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Neuro:
• • •
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Psych:
• • •
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Heme:
• • •
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Others, please specify:
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Medications:
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Allergies:
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Others, please specify:
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Family History:
• • •
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Others, please specify:
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Social History:
• • •
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Drug name:
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If CON Normal for all findings
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CON assessed and agreed
• • •
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CON assessed and disagree
• • •
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CON not assessed
• • •
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Select the below assessment options if agree
• • •
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Select the below assessment options if disagree
• • •
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Continue with
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Palliative care assessment Plan (VAS 0-10)
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Pain (current)
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Pain (minimum)
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Pain (maximum)
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Tiredness/ Fatigue
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Nausea
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Depression
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Anxiety
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Drowsiness/ Sleepiness
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Anorexia
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Shortness of Breath
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Constipation (Y/N)
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Secretions
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Delirium
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Discussed case with
• • •
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Past med records ordered/ reviewed
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Disposition/case Mgmt: Plan D/C in__ days
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to
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To ill to disposition or W/U in progress
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Length of visit in mins
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Critical Care
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D/C planning
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>50% of spent coord care &/or counseling
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Other
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