Palliative Care Consultation (Access in epic with <dot>palliativecare, select Southdale Pall consult) Test Zzburnsville MRN# 0029012140 Age: 21 year old Date of Birth: 12/24/1991 Date of Admission: (Not on file) Reason for consult: Pain management, Symptom management, Goals of care, Decisional support, Patient and family support, *** Requesting physician: *** Attestation: This patient has been seen and evaluated by me. Discussed with the team and agree with the findings and plan in this note. This patient was seen and evaluated by me separately from the house staff team. I have reviewed the note below and agree. I have seen and examined the patient and agree with the findings in this note except *** I have reviewed today's vital signs, medications, labs and imaging. Total time on the floor involved in the patient's care: *** minutes Percentage of time spent in counseling/care coordination: ***% Attending note: *** Advance Care Planning: Health Care Directive on file? Yes Health care agent: { :8200200} Comments: ***, {POLST forms :8200221} Code Status: { :8200198} Palliative Assessment and Plan: Functional assessment: Palliative performance scale: ***, ECOG: ***, *** Prognosis: *** Decisional capacity: { :8200215::"Intact"} Patient's understanding of illness: *** Patient goals of care: *** Diagnoses and recommendations: *** Chief Complaint: *** {History obtained from :8200072::"History is obtained from the patient"} History of Present Illness: This patient is a 21 year old { :8200201} male { :119162} who presents with *** Past Medical History: { :8200074} Recent Hospitalizations: Multiple hospitalizations in the ***, This patient has been hospitalized *** times in the past *** months Past Surgical History: This patient has no significant past surgical history I have reviewed this patient's past surgical history I have reviewed this patient's past surgical history and commented on sigificant events within the HPI Social History: This patient has no significant social history I have reviewed this patient's social history I have reviewed this patient's social history and commented on significant items within the HPI Palliative care social history:: Living situation: ***, Self-identifed support system: ***, Functional status: {:8200228}, Employment / education: ***, Activities / interests: ***, Use of community agencies: ***, *** Religious affiliation: { :8200235} Spiritual History: { :8200213::"No spiritual concerns identified"} Family History: { :8200077} Immunizations: { :8200314} Allergies: { :8200318} Medications: { :8201009} Review of Systems: { :8201019} Delirium Screen: Acute onset and fluctuating course? {YES NO N/A NO DEFAULT:4445::"No"} Inattention? {YES NO N/A NO DEFAULT:4445::"No"} Disorganized thinking? {YES NO N/A NO DEFAULT:4445::"No"} Altered level of consciousness? {YES NO N/A NO DEFAULT:4445::"No"} CAM score *** / 4 Physical Exam: {VITALS OPT:8200079::"Vitals were reviewed"} Constitutional: {:135965} Eyes: {:135966} ENT: {:135967} Neck: {:135968} Hematologic / Lymphatic: {:135969} Back: {:135970} Lungs: {:135971} Cardiovascular: {RUSH PE LEAVITT CARDIOVASCULAR W/ LISTS IP:135972} Abdomen: {:135973} Chest / Breast: {:135974} Genitounirinary: {:135975} Musculoskeletal: {RUSH PE LEAVITT MUSCULOSKELETAL IP:135976} Neurologic: {RUSH PE LEAVITT NEUROLOGIC W/ LISTS IP:135977} Neuropsychiatric: { :8200229} Skin: {:135978} Data: Vital signs reviewed past 24 hours. All lab results reviewed past 24 hours. Other relevant labs for course reviewed. All imaging results reviewed past 24 hours. Medications given over the past 24 hours reviewed.
TERRY KOPP, MD
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Lakes Palliative Sedation Order Set
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