Palliative Care Documentation Template

The team will partner with home health and hospice professionals skilled nursing facilities and others in the community to continue care that is in accordance with the patients goals for care.

Palliative care documentation template. Revisions to the plan of care using continuously updated comprehensive assessments of the patient and family status. Palliative care documentation and templates also present unique challenges as palliative care is provided in an interdisciplinary setting tells personal story outside of standard medical issues and must relay the overriding goals that drive the creation of a medical plan. The interdisciplinary team is responsible for continuously coordinating care and services based on assessed needs. An older etiquette form that is appreciated is to begin the consultation note with the phrase.

Reason for consultation i was asked to see this 87 year old man for problems related to shortness of breath and setting goals of care by dr. This template is critical to improving the process and documentation of clinical. This fast fact reviews key elements of the palliative care consutation note. And documenting accurate patient assessments and care plans are essential for certain aspects of care such as advance care planning.

Nursing home palliative care toolkit originally developed september 2013 revised june 2014 this material was prepared by healthcentric advisors the quality improvement organization support center for rhode. In palliative care documentation is at the heart of our communications. Sample consultation note in palliative care charles f. The plan of care is the most important document in hospice care.

Palliative care is appropriate for any patient regardless of age time of illness andor diagnosis depending upon the needs and wishes of the. Documentation templates hicm care manager activity tracking worksheet a concise tool to track the care managers work with an individual patient and includes list of billing codes. A communicate your findings b document the service you provided and c support your coding and billing activityin fast fact 266 the basic principles of consultation ettiquete were reviewed as they apply to palliative care clinicians. Excellence in interprofessional palliative care documentation.

Palliative care national clinical template pc nct the va hospice and palliative care hpc program office has sponsored the development of this reminder dialog template to document provider based palliative care consultations at all sites within vha. Von gunten md phd. Proper documentation of certain elements of a patients medical history and physical exam are also needed for billing and useful.