Palliative Care Follow-Up Note (Inpatient)

Date/Time: [Date and time of note entry]

Hospital Day: [Hospital day number]

Primary Team/Location: [Primary service and current location]

Reason for Follow-Up Today: [Concise reason for today's palliative follow-up]

Interval History

[1–2 sentence synopsis of why palliative care is involved and what has changed since the last note]

• Interval clinical events: [New diagnoses, procedures, complications, or treatment changes since last note]
• Symptoms most bothersome today: [Patient/family report of key symptoms; include one brief direct quote only if it clarifies goals/values/distress]
• Medication response/PRN use (last 24h): [Efficacy, adverse effects, PRN frequency and response]
• Communication updates: [Significant discussions or family meetings since last note]

(If patient unable to report, document source of information and limitation. Do not include a templated review of systems.)

Symptom Status

[Compact at-a-glance summary of current symptom burden: list relevant symptoms with severity/trend] (For top 1–2 symptoms driving management, add brief qualifier such as location, pattern, or response to intervention. Document "not assessed" with reason if a core symptom was deferred. Include standardized scale name/score if used today.)

Functional status: [Brief status relevant to disposition/prognosis]

Goals of Care & Communication

• Participants: [Names/roles; mode: in-person / phone / video]
• Capacity/Surrogate: [intact / impaired / fluctuating]; [Surrogate name and relationship if applicable]
• Illness Understanding: [Brief summary of patient/surrogate understanding of condition and trajectory]
• Goals/Values: [Key values/tradeoffs expressed; include one short quote only if clarifying]
• Treatment Preferences: [Code status]; [Escalation boundaries addressed today] (Document only items actually discussed.)
• Decisions & Next Steps: [What was decided]; [What remains undecided and why]; [Next scheduled discussion if applicable]

(If no goals discussion occurred today, note why and plan to revisit. If discussion was declined, document attempt and re-approach plan.)

Objective

(Include only data used in today's clinical reasoning.)

• Vitals/trends: [Pertinent values or trends influencing symptom management or prognosis]
• Focused exam: [Relevant findings supporting symptom assessment] (If no bedside exam, document "chart review only" and reason.)
• Key labs/imaging: [Pertinent results impacting today's plan]

Assessment & Plan

(Number problems in descending priority. For each problem: state what changed today, the specific plan, and explicit ownership when actions require others.)

1) [Problem]: [Brief assessment and what changed] — [Specific interventions with doses/routes as applicable; monitoring plan; contingency if not improving; ownership: Palliative will do X / Primary team to do Y]

2) [Problem]: [Assessment] — [Plan and ownership]

3) [Care coordination / Disposition]: [Hospice consideration status, barriers, referral status, caregiver readiness, anticipated timeline as relevant] — [Tasks and responsible parties]

(Add or remove numbered problems as needed. Convert missing information into tasks. Omit domains not addressed today.)

Follow-Up: [Plan for palliative care follow-up and triggers for earlier review]