Palliative Care Follow-Up Note (Outpatient)

Date/Time: [Date and time of visit]

Provider: [Clinician name and credentials]

Visit Modality: [in-person / video / telephone]

Primary Illness: [Primary diagnosis; stage/status; current treatment line if relevant]

Key Teams: [Oncology, PCP, other involved specialists]

Interval History & Symptoms

[Time since last palliative care visit] — [Brief summary of prior plan and focus areas]

[Interval events since last visit: hospitalizations, ED visits, treatment changes, procedures, or care transitions with dates]

[Response to prior palliative interventions — improved / worsened / unchanged; patient/caregiver perspective if stated]

Active symptoms addressed today: (Repeat block for each symptom. Do not include symptoms that were not assessed; either omit or state "[Symptom] — not addressed today.")

• [Symptom name]: [Severity 0–10 if available; patient-reported / caregiver-reported] — [prior → current trend]; [pattern/triggers/functional impact]; [current treatments and response]; [red flags present / absent]

Medication review: [Confirmed changes since last visit with name, dose, route, schedule; PRN use patterns; adherence barriers; adverse effects] (Use "Reviewed — no changes" if unchanged.)

Function & Psychosocial

• Functional status: [Performance status with trend, e.g., ECOG 2 → 3] (Omit score if not formally assessed.)
• ADLs/IADLs: [Specific changes; tasks requiring assistance; mobility; falls; assistive devices; home services]
• Caregiver/support: [Primary caregiver, capacity, strain, changes, respite resources]
• Psychosocial concerns: [Financial, transportation, practical issues addressed]
• Spiritual/existential: [Concerns discussed] (Only include if specifically discussed.)

Goals & ACP Status

Illness understanding: [Patient/family understanding; direct quotes if available]

Goals-of-care discussion: [Values, priorities, trade-offs, decisions discussed] (If not revisited: "Goals not revisited today; last discussed [date]; no change reported.")

• Surrogate decision-maker: [Name, relationship, contact] (If unknown, note plan to clarify.)
• Advance directive: [none / exists / reviewed / updated] [date/location]
• POLST/MOLST: [none / discussed / completed / reviewed / updated] [date] (If applicable.)
• Code status: [Full code / DNR / DNI / other] (If applicable.)
• Hospice status: [not relevant / discussed / eligible / referred / enrolled] (If relevant.)

Objective

Vitals: [Relevant vitals] (For telehealth, note patient-reported vitals if available.)

Exam: [Focused findings relevant to symptoms addressed] (For telehealth, state exam limitations.)

Data Reviewed: [Pertinent labs, imaging, outside records with dates and sources]

Assessment

[1–3 sentence summary: patient identity, serious illness context, overall trajectory, main issues today]

• [Problem 1]: [improved / stable / worsened; controlled / uncontrolled] — [brief clinical impression]
• [Problem 2]: [improved / stable / worsened; controlled / uncontrolled] — [brief clinical impression]

(Include both symptom problems and situational problems such as goals alignment, caregiver strain, care coordination.)

Plan

(Organize by problem in priority order. Include medications with dosing and rationale, non-pharmacologic strategies, monitoring/safety, contingency guidance, coordination actions, and follow-up timing.)

[Problem 1]: [Medication changes with dose/route/schedule and rationale; non-pharmacologic interventions; monitoring plan and thresholds; contingency guidance (if X, then Y); coordination with other teams; follow-up timing]

[Problem 2]: [Details as above]

Opioid safety (if applicable): [Bowel regimen; sedation/driving precautions; naloxone prescribed and education; safe storage/disposal counseling]

Coordination: [Messages sent, referrals placed, pending items from other teams]

Follow-up: [Timing, modality, and who will follow up]

Billing note: [Total time and activities if billing by time; ACP time if billing separately] (Omit if not applicable.)