Detailed Hospice Assessment Notes for Palliative Care

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.