Palliative Care Consult

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Palliative Care Consult

Date/Time: [Enter date and time of consult]

Patient Identification: [Patient initials or MRN, age, sex, pertinent background]

Reason for Consultation: [Brief statement of why palliative care consult requested]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

Social History:
(Hyphenated list)
- Tobacco: [type, amount, duration, quit date if applicable]
- Alcohol: [type, amount, frequency]
- Recreational substances: [type, frequency]
- Occupation: [current job, exposures]
- Living situation: [who lives with patient, home environment]

Advance Directives:
(hyphenated list)
- [Code status (e.g., full code, DNR/DNI)]
- [Living will: yes/no]
- [Healthcare proxy: name/contact]

Functional Status:
(in paragraphs)
[Describe mobility, ability to perform ADLs/iADLs, need for assistance]

Pain and Symptom Assessment:
(in paragraphs)
[Pain: location, intensity (0–10), quality, alleviating/aggravating factors;
Other symptoms: nausea, dyspnea, fatigue, etc.]

Psychosocial Assessment:
(in paragraphs)
[Mood, coping mechanisms, support system, caregiver burden]

Physical Examination:
(Hyphenated list)
- [Vital signs in one line if mentioned (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)]
- [Stated physical examination findings, one line per system. If a normal exam is mentioned, use standard phrasing (eg., Respiratory: Chest clear to auscultation bilaterally, no wheezes or crackles; Cardiac: Normal S1/S2, no murmurs, rubs or gallops; Abdomen: Soft, non-distended, non-tender.)]

Assessment & Plan:
(Use medical terminology if appropriate. Do not fabricate.)
[One-sentence patient summary including age, sex, and primary diagnosis if not redundant]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]

#) Goals of Care Discussion:
- [Document patient/family values, preferences, decisions made]