Palliative Care Consultation Note (Inpatient)

Consultation Details

Date: [date of encounter]

Time: [time]

Service Requesting Consult: [requesting service]

Information Sources: [patient / surrogate with relationship / bedside RN / chart review / other] (Note any limitations such as delirium, encephalopathy, language barrier, sedation, or mechanical ventilation.)

At-a-Glance Summary

• Consult question: [one-line consult question] (Use requester's wording if available.)
• Primary diagnosis and reason for hospitalization: [diagnosis and admission reason; state "not yet clarified" if unknown]
• Key symptoms today with severity: [pain severity; dyspnea severity; other symptoms as applicable] (Include numeric ratings or observed severity; label nonverbal assessments as clinician observation.)
• Decision-maker: [name, relationship, and contact if known; or "surrogate not yet identified" with plan to clarify]
• Current code status: [Full Code / DNR / DNI / DNR-DNI / Limited Interventions / Comfort-Focused / Not yet clarified] (State whether confirmed today and with whom.)
• Current goals of care framing: [patient/surrogate words or "not yet clarified"] (Use direct quotes when available.)
• High-priority recommendations:
  • [recommendation] (Specify who will act: primary team vs palliative care.)
  • [recommendation]
  • [recommendation] (Include 2-4 recommendations as applicable.)

Reason for Consult

[Consult question in requester's words if available]. [Palliative care team's framing: symptom management / goals clarification / advance care planning / disposition support / family support / other]. (One to three sentences.)

Clinical Summary

[One-liner: serious illness and current admission reason]. [What changed to prompt consult: symptom escalation / new complication / prognostic inflection point / family distress / disposition barrier]. [Pertinent disease trajectory and current treatment plan]. [Prior palliative or hospice involvement if any]. [Recent key events informing today's assessment]. (Concise narrative paragraph; focus on information that drives recommendations rather than full chart transcription.)

Symptom Assessment

Pain

Screening (required): [numeric rating with temporal frame (now / worst in past 24 hours) if patient can self-report; for nonverbal patients, document observed pain behaviors or validated nonverbal scale result labeled as clinician observation]. (If unable to assess, state reason.)

Assessment (required if pain present): [location], [frequency/pattern], [onset/duration], [quality/character], [aggravating factors], [alleviating factors], [impact on function/sleep/mood]. Current regimen: [analgesics with doses and schedule], [response to therapy], [side effects: constipation / sedation / nausea / other].

Dyspnea

Screening (required): [presence and severity], [context: at rest / with exertion / positional], [associated distress], [response to current therapies]. (For nonverbal patients, document observed respiratory effort labeled as clinician observation. If unable to assess, state reason.)

Other Symptoms

(Include only symptoms relevant to this patient; omit categories that are clearly not applicable.)

• Nausea/Vomiting: [presence, severity, triggers, response to therapy]
• Constipation/Bowel function: [last BM, stool pattern, laxative use and effect]
• Appetite/Weight: [oral intake, weight trend, cachexia features]
• Fatigue: [severity, impact on activity]
• Anxiety/Depression: [patient-reported distress or observed affect]
• Insomnia: [sleep initiation/maintenance, contributing factors]
• Delirium/Cognitive changes: [fluctuation, inattention, hallucinations, precipitants]
• Agitation: [severity, triggers, safety concerns]
• Secretions/Cough: [burden, effectiveness of current measures]
• Functional decline: [new losses, evolving care needs]
• Other patient-prioritized concerns: [as reported]

Psychosocial and Spiritual Screen

[Living situation and caregiver availability]. [Major stressors, coping strengths and concerns]. [Whether spirituality or religion informs coping or medical decisions; desire for chaplain involvement]. (If social work or chaplain assessments will be documented separately, note "assessment pending." Expand only when significant needs are identified.)

Functional Status

[Baseline function (ADLs, mobility) vs current function]. [Performance status: PPS / ECOG / Karnofsky] (label as estimated if not formally measured). [Nutritional trajectory or significant weight loss if relevant to prognosis or recommendations].

Decision-Making and Goals of Care

Capacity and Surrogate

Decision-making capacity (required): Patient [has / does not have] capacity for [specific decisions discussed today]. (If lacking capacity, state reason: delirium / encephalopathy / sedation / developmental disability / other.)

Surrogate/legal decision-maker (required): [name], [relationship], [contact information if available]. Legal basis: [healthcare proxy / guardian / next-of-kin per state law]. Documentation: [scanned advance directive / POA paperwork / POLST / MOLST / not yet located]. (If unknown, state "surrogate not yet identified" and plan to clarify.)

Prognostic Understanding and Information Preferences

[What patient/surrogate understands about illness and prognosis]. [Preferred level of prognostic detail]. [Misunderstandings requiring clarification]. (Attribute statements to source; do not infer.)

Goals, Values, and Preferences

[What matters most to patient: function / cognition / time at home / comfort / avoiding ICU / specific activities / relationships / other]. [Hopes]. [Worries]. [Unacceptable outcomes]. [Preferences regarding specific interventions as discussed: CPR / intubation / ICU escalation / dialysis / feeding tubes / transfusions / antibiotics]. (Use direct quotes for values and preferences when available, especially when guiding high-stakes decisions.)

Code Status (required)

Current order: [Full Code / DNR / DNI / DNR-DNI / Limited Interventions / Comfort-Focused / Not yet clarified]. [Confirmed today: yes / no] with [patient / surrogate name and relationship]. (If not discussed today, state reason and plan with timeline. Documentation must reflect discussion or attempted discussion, not only the existing order.)

Goals of Care Discussion Status (required)

[Discussed today / Attempted but patient/surrogate declined (document declination) / Deferred (state reason and plan)]. [What was discussed]. [What was decided]. [Next steps and responsible parties].

Pertinent History and Medications

• Key comorbidities affecting symptoms or prognosis: [curated list]
• Symptom-relevant medications: [opioids, anxiolytics, antiemetics, steroids, bowel regimen, others with doses, routes, schedules; note scheduled vs PRN]
• Recent medication changes: [changes and rationale]
• Relevant allergies/intolerances: [allergies affecting symptom management options]

Objective

• Vital signs: [pertinent values relevant to symptoms or recommendations]
• General appearance: [comfortable / mild distress / moderate distress / severe distress / cachectic / other]
• Respiratory effort: [work of breathing, respiratory rate and pattern, accessory muscle use, oxygen delivery]
• Mental status: [alertness, orientation, attention, affect]
• Targeted exam findings: [findings relevant to active symptoms: abdomen for constipation, neuro for delirium, skin for wounds, other]
• Key labs/imaging reviewed: [selected results informing assessment or recommendations]

Assessment and Recommendations

(Organize by descending clinical priority. For each problem, provide brief assessment followed by specific actionable recommendations. Explicitly state whether primary team or palliative care will act. Include monitoring targets and response parameters when relevant. Common problem categories: Pain, Dyspnea, Nausea/Constipation, Delirium/Agitation, Anxiety/Distress, Goals of Care/Communication, Code Status, Advance Care Planning Documentation, Family/Caregiver Support, Spiritual Distress, Disposition Planning—include only those relevant to this patient.)

[Problem]: [Brief assessment statement]

[Etiology/pathophysiology], [severity], [key supporting data].

• [Recommendation with specific medication/dose/route/frequency or intervention; monitoring plan; hold or escalation parameters] (Action by: [primary team / palliative care])
• [Additional recommendations as needed]

[Additional problems as applicable]

[Assessment]

• [Recommendations] (Action by: [primary team / palliative care])

Communication and Coordination

• Updates provided to: [primary team clinician name/role], [bedside RN], [case management], [other] ([verbal handoff / note-only])
• Family meeting: [planned / not indicated] (If planned: [proposed date/time], [attendees needed], [location or virtual platform].)
• Referrals placed: [chaplain / social work / hospice / ethics / other]
• Palliative care follow-up: [timing and purpose of next encounter]

Advance Care Planning Time

(Include only if billing separately for ACP services; otherwise omit this section.)

Voluntary discussion confirmed. Participants: [patient / surrogate names and relationships / caregivers present]. Topics discussed: [advance directives / goals and values / treatment preferences (CPR, intubation, artificial nutrition/hydration) / surrogate identification or confirmation]. Decisions made: [summary]. Total face-to-face ACP counseling time: [X] minutes.