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Patient Summary
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Interval Changes
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Plan
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Palliative Care Plan
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Pain and Symptom Management
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Functional Limitations Requiring Support: (Describe limitations & assistive devices required) )
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Family/Caregiver/Socioeconomic Support: (Describe)
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Psychosocial/Spiritual Support
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Prognostication
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Goals of Care and ACP
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Other
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Labs
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After Visit Summary Comments
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Follow-up Interval
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Patient Stratification
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Date:
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Status Descriptions
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Status 0: Indeterminate
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Status 1: Approaching Graduation
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Status 2: Progressing
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Status 3: Unstable
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Status 4: Long Term
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Graduate Today
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Graduation Criteria
• • •
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Status 0
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Indeterminate Status
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Status 1
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Status 1 Critiera
• • •
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Status 2
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Status 2 Criteria
• • •
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Status 3
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Status 3 Criteria
• • •
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Status 4
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Status 4 Criteria:
• • •
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Status Level Comments:
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