Goals of Care/Serious Illness Conversation Note (Oncology)

Date/Time of Conversation: [date and time]

Author/Service: [clinician name and role/service]

Encounter Type: [inpatient / outpatient / telehealth]

Primary Oncology Diagnosis: [diagnosis, stage, treatment status]

Reason for Discussion: [trigger for conversation]

Participants: [patient present yes/no; family/caregivers with relationship; interpreter if used; other team members]

(If information was not obtained or discussed, document "Not addressed today: [reason] and [plan]" rather than leaving fields blank. Use 1–2 brief direct quotes only for values-defining statements. Code status must be accompanied by confirmation that orders are placed per institutional policy.)

Capacity and Decision-Making

[Capacity statement] (1–2 sentences. If capacity is intact, a single line suffices. If patient lacks capacity, identify surrogate decision-maker, relationship, and basis for authority.)

Conversation Content

Illness Understanding: [Patient's understanding of diagnosis, prognosis, and treatment intent in their own words; information preferences if discussed]

Prognosis Discussed: [discussed / deferred / declined] [If discussed: summary using ranges and acknowledging uncertainty; patient/family reaction and comprehension. If deferred or declined: reason and plan to revisit.]

Values and Goals: [What matters most to the patient—priorities, fears, acceptable/unacceptable tradeoffs] (Use brief quotes for key values. Link stated values to clinical implications where relevant. Attribute values to patient or surrogate; label any clinician interpretation as such.)

Decisions and Preferences

Treatment Decision: [Decision context and why now; options discussed with benefits/burdens framed against patient goals; clinician recommendation if offered; decision reached or "no decision made today"; triggers to revisit]

Code Status: [Full Code / DNR / DNI / AND] — [confirmed / changed / not addressed today] (If changed, confirm corresponding orders placed. This documentation does not substitute for required orders.)

Advance Care Planning Documents: Advance directive [completed / on file / not on file / unknown]; Healthcare proxy/POA [name, relationship if applicable]; POLST/MOLST [completed / on file / not on file / unknown]. (Note any forms completed or offered today and plan for missing items.)

Summary for Care Team

(3–5 line synthesis for rapid handoffs.)

Bottom line: [patient's understanding]

Priorities: [top values/goals]

Decisions: [what was decided or that no decision was made]

Code status: [status]

Next: [action + responsible party + timeframe]

Follow-Up and Next Steps

Actions Completed: [referrals placed, orders entered, documents uploaded, team members notified]

Follow-Up Plan: [date/timeframe, responsible clinician, what will be revisited]

Billing Addendum

(Include only when billing ACP codes 99497/99498. ACP time must be separate from other medical management time.)

Voluntary: [confirmed yes/no]

ACP Time: [total minutes; start/stop times if required]

Participants: [names and relationships]

Content: [brief description—advance directives, code status, preferences discussed]

Medical Necessity: [clinical context for ACP today]