Encounter Type: This was an initial assessment visit for the patient.
ESAS:
- Pain Score: 4
- Tiredness Score: 6
- Nausea Score: 2
- Depression Score: 5
- Anxiety Score: 3
- Drowsiness Score: 4
- Appetite Score: 3
- Wellbeing Score: 5
- Dyspnea Score: 2
- Other Problem Score: 1
Palliative Performance Scale Score: The patient has a PPS score of 60%, indicating moderate assistance is required.
FAST Stage Assessment: The patient is at stage 4 of the FAST scale, showing mild cognitive decline.
Orientation: The patient correctly identified the year as 2024, the season as autumn, the month as November, the day as Friday, the date as 1 November 2024, the country as the United Kingdom, the state as England, the city as London, the building as St. Mary's Hospital, and the floor as the second floor.
Registration: The patient successfully named all three objects: apple, penny, and table.
Attention and Calculations: The patient counted backward from 100 by 7s as follows: 93, 86, 79, 72, 65.
Recall: The patient recalled all three objects: apple, penny, and table.
Language:
- Pencil and Watch Naming: The patient correctly named both objects.
- Phrase Repetition: The patient successfully repeated the phrase “No ifs, ands, or buts.”
- 3-Step Command: The patient followed all steps correctly.
- Read and Obey: The patient closed their eyes as instructed.
- Write a Sentence: The patient wrote a complete sentence with a subject and verb.
- Copy the Design: The patient accurately copied the design.
- Total Score: The patient achieved a total cognitive score of 28.
Depression Screening
PHQ-2:
1. Have you felt little interest or pleasure in doing things?: Several days
2. Have you felt down, depressed, or hopeless?: Several days
PHQ-2 Total Score: 3
PHQ-9:
1. Little interest or pleasure in doing things: Several days
2. Feeling down, depressed, or hopeless: Several days
3. Trouble falling or staying asleep: Nearly every day
4. Feeling tired or having little energy: More than half the days
5. Poor appetite or overeating: Several days
6. Feeling bad about yourself: Several days
7. Trouble concentrating: More than half the days
8. Moving or speaking slowly: Not at all
9. Thoughts of being better off dead: Not at all
PHQ-9 Total Score: 10
Delirium Assessment
Non-ICU CAM:
1. Acute Onset or Fluctuating Course: No
2. Inattention: No
3. LOC: No
4. Disorganized Thinking: No
5. Delirium Suspected?: No
Morse Fall Risk Assessment:
- History of Falling: Yes
- Secondary Diagnosis: Yes
- Ambulatory Aids: Cane
- IV/Heparin Lock: No
- Gait/Transferring: Steady
- Mental Status: Oriented
- Score: 45
Psychosocial
Stress Factors:
- Patient Stress Factors: Financial concerns, health deterioration
- Family Stress Factors: Caregiver burden
Coping Response:
- Patient Coping: Utilizes meditation and support groups
- Family: Relies on extended family support
Spiritual-Cultural:
1. Who are the significant people in your life?: Spouse, children
2. What are the most comforting spiritual practices in your life?: Prayer, meditation
3. How is your faith and/or support system affected by your illness?: Faith remains strong, support system is crucial
4. What concerns, feelings, or thoughts do you have about your illness?: Concerned about future independence
5. Would you like spiritual care visits from a hospital chaplain?: Yes
6. Would you like to contact your community or faith minister?: No
Referrals Made: Referred to social work and chaplaincy services.
Decision to Forgo Treatment: The patient has decided to forgo aggressive chemotherapy.
Team Impact: The team will focus on palliative care and symptom management.
Discharge Disposition: The patient will continue with hospice care at home.
Encounter Type (Include only if explicitly stated. Indicate whether the visit was an initial assessment, follow-up visit, symptom management evaluation, or other encounter type. Write this section in a full sentence.)
Encounter Type: [Enter type of encounter conducted]
ESAS (Each score should be included if explicitly assessed. Document on a scale as used clinically, summarised in a single paragraph or as inline bullet points if already present in the template.)
Pain Score: [Enter pain score]
Tiredness Score: [Enter tiredness score]
Nausea Score: [Enter nausea score]
Depression Score: [Enter depression score]
Anxiety Score: [Enter anxiety score]
Drowsiness Score: [Enter drowsiness score]
Appetite Score: [Enter appetite score]
Wellbeing Score: [Enter wellbeing score]
Dyspnea Score: [Enter dyspnea score]
Other Problem Score: [Enter other symptom score if applicable]
Palliative Performance Scale (Include score only if performed. Write as a single sentence noting level of function based on PPS.)
Palliative Performance Scale Score: [Enter PPS score]
Functional Assessment Staging of Alzheimer’s Disease (FAST) (Include only if assessed. Note stage of functional decline using the FAST system for patients with Alzheimer’s or other cognitive decline.)
FAST Stage Assessment: [Enter FAST stage]
Orientation (Write responses in a sentence or inline format based on how it was documented. Include only if cognitive orientation assessment was performed.)
What YEAR is it?: [Enter patient’s response]
What SEASON is it?: [Enter patient’s response]
What MONTH are we in?: [Enter patient’s response]
What DAY of the week is it?: [Enter patient’s response]
What is today’s DATE?: [Enter patient’s response]
What COUNTRY are we in?: [Enter patient’s response]
What STATE are we in?: [Enter patient’s response]
What CITY are we in?: [Enter patient’s response]
What building are you in?: [Enter patient’s response]
What floor of the building are you?: [Enter patient’s response]
Registration (Include performance on object recall if assessed. Document whether the patient could name the items as prompted.)
Name these 3 objects (APPLE, PENNY, TABLE): [Enter patient’s performance]
Attention and Calculations (Include responses only if performed. Document the first five responses for evaluation of attention and cognitive processing.)
Begin with 100 and count backward by 7s: [Enter responses]
Recall (Include this paragraph if recall was assessed. State how many of the original items the patient remembered.)
Ask for the names of all three objects from earlier: [Enter number of correct answers and objects recalled]
Language (Include this language and comprehension testing if conducted. Write results using a consistent clinical tone.)
Pencil and Watch Naming: [Enter patient’s ability to name objects]
Phrase Repetition: “No ifs, ands, or buts”: [Enter result]
3-Step Command: [Enter performance on each step]
Read and Obey: CLOSE YOUR EYES: [Enter response]
Write a Sentence: [Enter whether patient could write sentence with subject and verb]
Copy the Design: [Enter result based on visual-motor integration]
Total Score: [Enter total cognitive or MMSE-style score if applicable]
(Only include if explicitly documented.)
Depression Screening
PHQ-2
1. Have you felt little interest or pleasure in doing things?: [Enter frequency]
2. Have you felt down, depressed, or hopeless?: [Enter frequency]
PHQ-2 Total Score: [Enter total]
PHQ-9 (Include depression screening in full detail if assessed. Document each item and total scores if available.)
1. Little interest or pleasure in doing things: [Enter frequency]
2. Feeling down, depressed, or hopeless: [Enter frequency]
3. Trouble falling or staying asleep: [Enter frequency]
4. Feeling tired or having little energy: [Enter frequency]
5. Poor appetite or overeating: [Enter frequency]
6. Feeling bad about yourself: [Enter frequency]
7. Trouble concentrating: [Enter frequency]
8. Moving or speaking slowly: [Enter frequency]
9. Thoughts of being better off dead: [Enter frequency]
PHQ-9 Total Score: [Enter score]
Delirium Assessment
Non-ICU CAM
1. Acute Onset or Fluctuating Course: [Enter yes/no]
2. Inattention: [Enter yes/no]
3. LOC: [Enter yes/no]
4. Disorganized Thinking: [Enter yes/no]
5. Delirium Suspected?: [Enter yes/no]
ICU CAM (Use either the Non-ICU CAM or ICU CAM format. Include only if delirium screening was performed.)
Step 1: Acute onset or Fluctuating course: [Enter yes/no]
Step 2: Inattention: [Enter yes/no]
Step 3: Altered LOC: [Enter yes/no]
Step 4: Disorganized Thinking: [Enter yes/no]
Step 5: Delirium Present?: [Enter yes/no]
Morse Fall Risk Assessment (Include each Morse element if assessed. Summarise in brief paragraph or list format.)
History of Falling: [Enter yes/no]
Secondary Diagnosis: [Enter yes/no]
Ambulatory Aids: [Enter aids used]
IV/Heparin Lock: [Enter yes/no]
Gait/Transferring: [Enter findings]
Mental Status: [Enter status]
Score: [Enter fall risk score]
Psychosocial
Stress Factors
Patient Stress Factors: [Enter stressors]
Family Stress Factors: [Enter stressors]
Coping Response
Patient Coping: [Enter description]
Family: [Enter description]
(Include psychosocial and emotional observations only if assessed. Describe family and patient coping mechanisms and current emotional support systems.)
Spiritual-Cultural (Summarise this section as a paragraph if preferred. Include any spiritual distress or requests.)
1. Who are the significant people in your life?: [Enter names or roles]
2. What are the most comforting spiritual practices in your life?: [Enter practices]
3. How is your faith and/or support system affected by your illness?: [Enter description]
4. What concerns, feelings, or thoughts do you have about your illness?: [Enter responses]
5. Would you like spiritual care visits from a hospital chaplain?: [Enter yes/no]
6. Would you like to contact your community or faith minister?: [Enter yes/no]
Note: Patient declines need for spiritual care support at this time. (Include this line only if relevant.)
Referrals Made: [Enter referrals to specialists, chaplaincy, social work, etc.]
Decision to Forgo Treatment: [Enter any treatment limitations or refusal documented]
Team Impact: [Enter team communication or changes made following assessment]
Discharge Disposition: [Enter plan if relevant for transfer, discharge, or continued hospice care]
(Never come up with your own patient responses, symptoms, or documentation content – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing – simply omit the section.)
