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Palliative Care Physician Template

Hospital Initial assessment

A professional Palliative Care Physician template for healthcare professionals.
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Specialty

Palliative Care Physician

Used

30 times

Type

Note

Last edited

1/22/2026

Created by

Bharat Bahl

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About this template

The Hospital Initial Assessment template is designed for palliative care physicians to document comprehensive initial evaluations of patients admitted for palliative care. This template includes sections for recording the patient's living situation, medical history, recent illness course, examination findings, and goals of care. It also covers essential details such as code status, medical power of attorney, and specialist consultations. The template facilitates thorough documentation, ensuring that all relevant aspects of the patient's condition and care plan are captured, aiding in the delivery of personalized and compassionate care.

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Date of admission: 1 November 2024 Room number: 305 Health Card number: 123456789 Reason for Palliation: Advanced metastatic cancer Code Status: DNIR Referring physician: Dr. John Smith Family physician: Dr. Emily Brown **Living Situation and functional status:** Apartment, requires assistance with ADLs, uses a walker, independent with banking and cooking **Medical Power of Attorney/SDM/NOK:** Daughter, Jane Doe **Recent medical illness course:** Recent hospitalization for pneumonia **On Exam and Wounds:** Heart rate 88 bpm, blood pressure 120/80 mmHg, oxygen saturation 95%, resp rate 18, temperature 37°C, abdomen soft, clear breath sounds, normal heart sounds, no murmurs, mild oedema in lower extremities, no wounds **Past medical history:** Hypertension, Type 2 Diabetes, Chronic Kidney Disease **Labs:** Sodium 140 mmol/L, Creatinine 1.5 mg/dL, Liver enzymes normal, Albumin 3.5 g/dL **Imaging results:** Echocardiogram shows normal function, CT scan reveals metastatic lesions in the liver **Specialist consultations:** Oncologist, Nephrologist **Ins and Outs:** Regular bowel movements, adequate food intake, eats breakfast, lunch, and dinner Medications: Metformin, Lisinopril, Furosemide ESAS: Pain - Moderate ache Tiredness - Moderate fatigue Drowsiness - Mildly sleepy Nausea - Occasional vomiting Lack of Appetite - Food doesn't taste the same SOB - Mild shortness of breath Depression - Low mood Anxiety - Mild stress Best Well Being - 5/10 Sleep - 6 hours per night Bowel movements - Regular **Religion:** Christian Goals of care: Focus on comfort and quality of life, avoid aggressive treatments **Overall impression and Plan:** To summarize, the patient is in the palliative stage of metastatic cancer with a focus on symptom management and quality of life. The plan is to continue current medications, monitor symptoms, and provide supportive care.

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