Palliative Consult Note
Date of consult -[date name="date1" default="today"] Location - [select name="loc" value="Riverside|Enclave"] Patient Referred by -[text name="variable_1" default="Dr."] Demographics and Patient Status [textarea name="demo1" default=""] Hospital Course [textarea name="hospcourse" default=""] History of Presenting Illness [comment memo="write HPI below"] [textarea name="variable5" default=""] A palliative consultation was requested by the patients attending physician to alleviate the burden associated with the following condition/s [checkbox name="palliative_1" value="Adult Failure to Thrive|ALS|Alzheimer’s Disease|Breast Cancer|Cancer|Chronic Obstructive Pulmonary Disease (COPD)|Colon Cancer|Congestive Heart Failure|COVID-19|Dementia|Head and Neck Cancer|HIV/AIDS|Huntington’s Disease|Kidney Disease|Leukemia and Lymphoma|Liver disease|Lung Cancer|Multiple Myeloma|Multiple Sclerosis|Ovarian Cancer|Pancreatic Cancer|Parkinson’s Disease|Prostate Cancer|Pulmonary Fibrosis|Sickle Cell Anemia|Stroke|"] [conditional field="palliative_1" condition="(palliative_1).is('')"][textarea name="Palliativetxt1" default=""][/conditional] Allergies -[textarea name="allergies_1" default="No Known Allergies"] Past Surgical History -[select name="Surgical_1" value="Non Contributory|"][conditional field="Surgical_1" condition="(Surgical_1).is('')"][checkbox name="Surgical_2" value="R Hip replacement|L Hip replacement|R knee replacement|L knee replacement"], [textarea name="Surgery_text" default=""][/conditional] Family History -[textarea name="Surgery_text" default="Non contributory"] Social History - [select name="social1" value="This patient denies smoking cigarettes, denies drinking alcohol, denies recreational drug use.|"] [conditional field="social1" condition="(social1).is('')"][textarea name="socialtxt1" default="This patient reports use of"][/conditional] Medication - [select name="Med1" value="I have reviewed the patients medications|"][conditional field="Med1" condition="(Med1).is('')"][textarea name="Medtxt1" default=""][/conditional] Advanced Care Directives - Health Care Proxy - [select name="HCP1" value="Yes|No"] [conditional field="HCP1" condition="(HCP1).is('Yes')"] [textarea name="HCPtxt1" default=""] [comment memo="Name, Relationship to patient, Phone number"][/conditional] [checkbox name="ACD_2" value="Living Will|Documentation of Oral Advance Directive|Durable Power of Attorney|DNR|DNI|No Feeding Tube|Do Not Hospitalize|"][conditional field="ACD_2" condition="(ACD_2).is('')"][textarea name="ACDtext1" default=""] [comment memo="Discuss any additional information regarding ACD"][/conditional] Change in Patient's Wishes - [select name="Wish1" value="No|Yes"][conditional field="Wish1" condition="(Wish1).is('Yes')"] [textarea name="ACDtext1" default=""][/conditional] Review of Systems [select name="ROS_1" value="This patient is able to provide appropriate answers|This patient is nonverbal/otherwise unable to assess"][conditional field="ROS_1" condition="(ROS_1).is('This patient is able to provide appropriate answers')"] [comment memo="Default will be negative. Click if positive"] General [checklist name="ROS1" value="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls"] Neurological [checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"] HEENT [checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia"] Cardiovascular [checklist name="ROS4" value="Chest Pain|Palpitations"] Respiratory [checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"] Gastrointestinal [checklist name="ROS6" value="Nausea|Vomitting|Diarrhea|Constipation|Abdominal Pain"] Genitourinary [checklist name="ROS7" value="Urinary incontinence|Dysuria"] Musculoskeletal [checklist name="ROS8" value="Muscle Weakness|Joint pain|Joint stiffness"] [/conditional] Physical Exam [comment memo="Please write in Vitals"] Vital Signs - [textarea name="VS1" default="BP- mmgHg T- °F P- beats/min R- breaths/min"] General - [textarea name="Pe1" default="No acute distress, Well developed, well nourished, Afebrile"] Neurological - [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"] HEENT - [textarea name="Pe3" default="Head is normocephalic, atraumatic. Bilateral pupils equal and reactive to light and accommodating. No scleral icterus, no conjunctival pallor. No neck masses palpated."] Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits. No crackles. No rhales or rhonchi."] Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremeties. Adequate perfusion. No peripheral signs of cyanosis. Regular rate and rhythm. No murmurs auscultated."] Gastrointestinal - [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness. Bowel sounds auscultated."] Musculoskeletal - [textarea name="Mskphys" default="No difficulty with passive ROS Strength 5/5 bilateral upper extremeties. "] Assessment [textarea name="Ass1" default=""] Plan [textarea name="Plan1" default=""] [comment memo="There are 3 choices. 1. Patient only. 2.Patient+family. 3. Patient but counseling directed to family only"] [select name="totaltime" value="Total time spent with the patient was approximately 70 minutes. Greater than 50% of the time was spent counseling, coordinating care for the patient. In addition to obtaining history, examining the patient, reviewing all pertinent diagnosis, diagnostic studies, reviewing active orders, documenting care.|Total time spent with the patient and family was approximately 70 minutes. Greater than 50% of the time was spent counseling, coordinating care for the patient. In addition to obtaining history, examining the patient, reviewing all pertinent diagnosis, diagnostic studies, reviewing active orders, documenting care|Total time spent with the patient and family was approximately 70 minutes. Greater than 50% of the time was spent counseling, coordinating care for the patient. In addition to obtaining history, examining the patient, reviewing all pertinent diagnosis, diagnostic studies, reviewing active orders, documenting care."] [select name="ACPDiscussion" value="|Approximately 30 minutes were spent discussing advanced care planning. I have counseled the patient on end of life issues, answering questions and coordinating care.|Greater than 30 minutes were spent discussing advanced care planning. I have counseled the patient on end of life issues, answering questions and coordinating care."]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.48, 58 form elements, 91 boilerplate words, 1 text boxes, 22 text areas, 1 dates, 3 checkboxes, 8 check lists, 9 drop downs, 6 comments, 8 conditionals, 104 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote