Palliative Care Progress Note

Date/Time of Service: [Date and time of encounter]

Patient: [Patient name and identifiers]

Author/Role: [Clinician name and role]

Setting: [inpatient / clinic / home / telehealth / SNF / hospice facility]

Primary Team/Referring Clinician: [Team or clinician name and service]

History Source: [patient / caregiver / chart / interpreter-assisted] (Note reliability limitations if applicable.)

Reason for Visit

[Chief concern in patient-centered terms and clinical trigger if relevant]

Summary & Recommendations

(Provide 3–6 bullets synthesizing the clinical picture for non-palliative clinicians. Abbreviate or omit for straightforward outpatient follow-ups.)

• [Serious illness context]
• [Top active symptoms with severity and trend]
• [Current goals-of-care headline]
• [Major plan changes or recommendations]
• [Key coordination items]

Subjective

(Document only what changed or is decision-relevant since last palliative encounter.)

Interval History: [Symptom trajectory, functional impact, treatment response and side effects, relevant medical course updates] (Use brief direct quotes when needed to accurately convey values or symptom descriptors.)

Symptom Assessment: [Active symptoms with severity rating, trend, and functional impact; timeframe assessed; reporter] (If using validated tool such as ESAS-r or IPOS, include score and interpretation. Only document symptoms that were assessed.)

Treatment Response: [Current symptom-related medications and nonpharmacologic measures; adherence barriers; side effects; PRN effectiveness; bowel regimen status if on opioids]

Psychosocial/Spiritual: [Mood, coping, distress, caregiver strain, spiritual concerns as relevant] (Attribute interdisciplinary input when applicable. Include suicidal ideation assessment when clinically indicated.)

Goals of Care Update: (Include when clinical status changed, a goals conversation occurred, or code status was addressed.)

• [Decision-making capacity: intact / impaired / uncertain]
• [Surrogate/healthcare agent identity]
• [Illness understanding: patient and family perspective]
• [Values, priorities, and acceptable trade-offs]
• [Current goal-concordant care approach]
• [Code status] (Note whether confirmed today vs per chart.)
• [Advance directives/POLST status]
• [Family meeting summary: participants, decisions, next steps] (Include if meeting occurred.)

Objective

Vitals: [Relevant vital signs] (For telehealth, state "not obtained" rather than importing old values.)

Exam: [Focused findings relevant to symptom drivers and comfort] (Document only what was performed.)

Data: [Pertinent labs, imaging, or consult findings affecting palliative decisions]

Functional Status: [Trajectory: improving / stable / declining; standardized measure if used; ADL dependence; oral intake]

Assessment & Plan

[Synthesis: diagnosis and trajectory, key symptom burdens, goals-of-care anchor]

[Problem 1]

Assessment: [Severity, trend, suspected etiology, prior treatments and response]

Plan: [Pharmacologic and nonpharmacologic interventions; monitoring targets; contingency triggers; responsible party; safety adjuncts as indicated]

[Problem 2]

(Repeat for additional active issues including psychological, social, spiritual, and ethical/legal matters as relevant.)

Care Coordination

• [Interdisciplinary involvement today]
• [Communications completed]
• [Referrals placed]
• [Transition/discharge planning needs]
• [Follow-up timing and reassessment focus]

Advance Care Planning

(Include when ACP was substantively performed or requires auditable documentation.)

• [Voluntariness and participants]
• [Content summary and decisions]
• [Time spent (minutes)]
• [Documents completed/updated]

Time-based billing: [Total clinician time (minutes)] (Include if applicable.)

Signature: [Electronic signature with credentials]