Palliative Care Consultation Note (Outpatient)

Encounter date and time: [Encounter date and time]

Author: [Author name and credentials]

Clinic location: [Clinic location]

Encounter type: Initial outpatient palliative care consultation

Referring clinician and reason for consult: [Referring clinician name]; [Consultation question]

Participants present: [Patient], [Caregiver name and relationship], [Interpreter: language and modality if used] (Label information sources throughout the note: patient report, caregiver report, prior records, clinician observation.)

Encounter limitations: [Cognitive impairment / language barrier / incomplete records / time constraints / other limitation affecting visit] (Omit this field entirely if no limitations.)

Chief Concern / Consultation Question

[Patient-stated reason for visit] (Use direct quotes for emotionally salient content.)

[Referring clinician's consultation question]; [Additional patient priorities if multiple concerns]

Executive Summary

[Demographics and primary serious illness]; [Current disease trajectory and treatments]; [Functional baseline]; [Top symptoms and psychosocial/caregiver issues]; [Goals-of-care planning status] (Write as a concise 3–6 sentence paragraph designed for copy-forward to future palliative notes with updating.)

History of Present Illness

Illness Understanding and Trajectory

[Timeline of diagnosis and major turning points]; [Recent hospitalizations or ED visits with dates]; [Patient's understanding of current treatment plan]; [Prognostic understanding as patient describes it]; [Information preferences regarding detail level and who should receive updates] (Use direct quotes for key statements about understanding, hopes, and worries.)

Symptom Assessment

(For each active symptom, document severity, functional interference, triggers/relievers, current therapies with doses, non-pharmacologic strategies, and adverse effects or barriers. Include only relevant symptoms—do not force documentation of symptoms that are absent.)

• [Symptom name]: [Severity]; [Functional interference]; [Triggers and relievers]; [Current pharmacologic therapies]; [Non-pharmacologic strategies]; [Adverse effects or barriers]

(Repeat for each active symptom such as pain, dyspnea, nausea/vomiting, constipation, appetite/weight, fatigue/sleep, anxiety/depression, cognition.)

Function and Quality of Life

[Performance status or ADL/IADL assessment]; [Mobility and assistive devices]; [Typical day and current hardest challenges]; [Patient-defined quality-of-life priorities and acceptable trade-offs]

Coping and Psychological Status

[Coping style and what has helped previously]; [Key worries and hopes]; [Mood and anxiety symptoms]

[Safety screening findings and actions taken] (Include self-harm risk, unsafe home situation, or substance concerns only when clinically indicated.)

Social Support and Caregiver Assessment

[Household composition and primary caregiver]; [Caregiver capacity, burden, and needs]; [Backup caregivers and respite options]; [Transportation, financial/insurance barriers, other social determinants] (If caregiver not present, document how their needs were assessed.)

Spiritual and Cultural Considerations

[Sources of meaning and faith community supports]; [Existential distress]; [Cultural values affecting decisions]; [Communication preferences] (Include only when relevant to care planning.)

Relevant Background

Medical history: [Key comorbidities influencing symptom management or medication choices]

Medications: [Symptom-focused medications with doses]; [High-risk medications]; [Relevant interactions] (Cite source and date if from external records.)

Allergies: [Allergen, reaction type, severity]

Substance use: [Alcohol, tobacco, other substances] (Include when prescribing controlled substances or when relevant to safety planning.)

Objective

Vital signs: [Vital signs if collected]

Physical exam: [Focused exam findings relevant to symptoms and medication safety: general appearance, respiratory effort, edema, abdominal exam, mental status, gait, other pertinent findings]

Performance status: [Observed functional status]

Relevant diagnostics: [Recent labs or imaging with dates and clinical relevance] (Include only results pertinent to palliative plan.)

Exam limitations: [What could not be assessed and why] (Include only if applicable.)

Assessment

[Serious illness context and current trajectory statement] (Synthesize and prioritize; interpret rather than repeat HPI.)

[Problem 1]: [Brief synthesis including key factors, contributing conditions, and risks]

[Problem 2]: [Brief synthesis]

(Continue for additional problems in order of severity or urgency, including symptom diagnoses, psychosocial/caregiver issues, and decision-making status.)

Plan

(Organize by problem. For each, include goal, interventions, safety measures, monitoring plan, and escalation instructions.)

Symptom Management

[Symptom problem]: [Goal for next interval]; [Pharmacologic interventions with doses and titration parameters]; [Non-pharmacologic measures]; [Safety precautions such as bowel regimen with opioids, sedation/falls precautions, naloxone if indicated]; [Monitoring plan and responsible party]; [Escalation instructions]

(Repeat for each active symptom problem.)

Coping and Support

[Counseling provided and coping strategies discussed]; [Referrals: social work, psychology, psychiatry, chaplaincy, community resources]; [Crisis/safety plan if indicated]

Caregiver Plan

[Education provided]; [Respite planning and backup arrangements]; [Home health or supportive services ordered]; [Caregiver follow-up plan]

Advance Care Planning

(Require explicit documentation or citation to verified source with date—do not infer code status, surrogate, AD status, or capacity.)

Patient understanding and values: [What matters most; trade-offs between longevity and comfort/function]

Code status: [Full code / DNR / DNAR-CC / Not discussed today] (If from prior documentation, cite source and date.)

Surrogate decision-maker: [Name, relationship, contact] or [Not yet identified] (If documented elsewhere, cite source and date.)

Advance directive/POLST: [Document type, status, location, date]; [Next steps]

ACP discussion today: [Summary of discussion]; [Participants]; [ACP time: ___ minutes, separate from E/M] (Include only if ACP conducted; confirm voluntary face-to-face discussion.)

If ACP not discussed: [Reason]; [Plan to revisit]

Care Coordination

[Communication to referring clinician and specialists]; [Referrals placed]; [Community resources and home services arranged]; [Medication access issues and follow-up]

Longitudinal Care Roadmap

Follow-up: [Interval and rationale]

Between-visit touchpoints: [Nurse calls, pharmacist checks, social work follow-up with timing]

Anticipated milestones: [Decision points, treatment response assessments, transition points]

Escalation triggers: [Specific symptom thresholds or events prompting urgent contact]

Patient/caregiver instructions: [What to track; when to call; medication change summary]

Communication and Disposition

[Summary provided to patient/caregiver]; [Written instructions given]; [After-hours contact and safety-net instructions]; [Next appointment or scheduling plan]

Billing Addendum

(Include when relevant to support coding.)

E/M level basis: [Medical decision making / Time-based]

If time-based: Total clinician time on date of encounter: [___ minutes] (Includes prep, history, exam, counseling, ordering, documentation, coordination.)

ACP if billed separately: ACP time: [___ minutes]; [Voluntary face-to-face confirmed]; Participants: [Names and roles] (ACP time must be distinct from E/M time.)