[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-572293-105":3,"detail-sidebar-cat-1-en-105":74,"doc-detail-572293-en":120},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":67,"head_meta":69,"extra_data":71,"updated_unix":73},105,"en","sample-palliative-care-consultationevaluation-template-hospice-and-palliative-aprn-essential-information","Sample Palliative Care Consultation/Evaluation Template - Hospice and Palliative APRN Essential Information","","Sample palliative care consultation and evaluation template designed to support comprehensive documentation for hospice and palliative care advanced practice registered nurse (APRN) initial assessments. The form guides systematic capture of patient identifiers, admission and evaluation dates, admitting and attending clinicians, referral reasons, and a structured history including subjective chief complaint, symptom review elements, and pain characterization. It also includes palliative review of systems, advanced directives and surrogate decision-making, resuscitation status (e.g., POLST/MOLST), spiritual history, and objective physical exam essentials.",{"@graph":14,"@context":66},[15,34,49],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/sample-palliative-care-consultationevaluation-template-hospice-and-palliative-aprn-essential-information/572293/",4,{"url":32,"name":10,"@type":35,"author":36,"headline":10,"publisher":39,"fileFormat":42,"inLanguage":8,"description":12,"dateModified":43,"datePublished":43,"encodingFormat":42,"isAccessibleForFree":44,"interactionStatistic":45},"DigitalDocument",{"name":37,"@type":38},"lugxt","Person",{"url":19,"name":40,"@type":41},"DocShare","Organization","application/pdf","2026-10-13",true,{"@type":46,"interactionType":47,"userInteractionCount":4},"InteractionCounter",{"@type":48},"ViewAction",{"@type":50,"mainEntity":51},"FAQPage",[52,58,62],{"name":53,"@type":54,"acceptedAnswer":55},"What patient and admission fields are included in the template?","Question",{"text":56,"@type":57},"The template requests patient name, medical record number, date of birth, admission date into the care setting, and details for admitting physician and relevant clinicians. It also includes the reason for consultation and the date of evaluation or visit.","Answer",{"name":59,"@type":54,"acceptedAnswer":60},"How does the template structure symptom and pain documentation?",{"text":61,"@type":57},"It provides a symptom review section covering location, quality, severity, duration, timing, context, modifying or exacerbating factors, and associated signs and symptoms. For pain, it includes pain or symptom history, description, intensity scoring (0–10), interference with daily life (0–10), and worst/best levels over the last two weeks.",{"name":63,"@type":54,"acceptedAnswer":64},"Which end-of-life planning and treatment-limitation elements are documented?",{"text":65,"@type":57},"It collects surrogate decision-maker information, locations of advance directive documents, attitudes toward place of death, funeral wishes, and information sharing preferences. It also captures resuscitation status elements such as no chest compressions, no defibrillation/electrocardioversion, and other life-sustaining treatment limitations, referencing common POLST/MOLST-style orders.","https://schema.org",{"og:url":32,"og:type":68,"og:title":10,"og:site_name":40,"og:description":12},"article",{"robots":70,"canonical":32},"index,follow",{"doc_id":72,"site_id":7},572293,1791926602,{"code":4,"msg":75,"data":76},"success",[77,82,87,92,97,102,106,111,116],{"id":78,"doc_module":22,"doc_module_name":25,"category_name":79,"show_sort_weight":80,"slug":81},11,"Presentations",90,"presentations",{"id":83,"doc_module":22,"doc_module_name":25,"category_name":84,"show_sort_weight":85,"slug":86},12,"Resumes",80,"resumes",{"id":88,"doc_module":22,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},14,"Invoices",70,"invoices",{"id":93,"doc_module":22,"doc_module_name":25,"category_name":94,"show_sort_weight":95,"slug":96},15,"Posters",60,"posters",{"id":98,"doc_module":22,"doc_module_name":25,"category_name":99,"show_sort_weight":100,"slug":101},16,"Social Media",50,"social-media",{"id":103,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":104,"slug":105},17,40,"forms",{"id":107,"doc_module":22,"doc_module_name":25,"category_name":108,"show_sort_weight":109,"slug":110},18,"Letters",30,"letters",{"id":112,"doc_module":22,"doc_module_name":25,"category_name":113,"show_sort_weight":114,"slug":115},21,"Paper Templates",5,"papers-templates",{"id":117,"doc_module":22,"doc_module_name":25,"category_name":118,"show_sort_weight":4,"slug":119},158,"General","general-158",{"code":4,"msg":75,"data":121},{"doc_id":72,"user_id":122,"nickname":37,"user_avatar":123,"doc_module":22,"category_id":103,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":124,"file_id":125,"file_url":126,"file_type":127,"file_size":128,"view_count":4,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":129,"language":130,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":131,"faqs":132,"seo_title":133,"seo_description":12,"update_tm":73,"read_time":26},3985747862600,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","ESSENTIAL INFORMATION FOR THE HOSPICE  \nAND PALLIATIVE ADVANCED PRACTICE REGISTERED NURSE 1  \nSample Palliative Care  \nConsultation/Evaluation Template  \nUsing a template facilitates comprehensive documentation that captures the complexity of palliative care evaluation and demonstrates the high level of assessment that an APRN performs during an initial evaluation. The following template offers important areas to highlight and document the comprehensive and complex services that the hospice and palliative APRN provides.  \nName of Patient:  \nMedical Record Number:  \nDate of Birth:  \nDate of Admission into Hospital/Hospice/Home Health/Skilled Facility: Admitting Physician:  \nAttending Clinician:  \nReferring Clinician:  \nReason for Consultation:  \nDate of Evaluation/Consultation/Visit:  \nPalliative APRN Consultant:  \nHISTORY (ELEMENTS)  \nSubjective/Chief Complaint  \nReason for Admission/History of Present Illness State who provided history or where history obtained  \nSymptom Review  \nLocation:  \nQuality:  \nSeverity:  \nDuration:  \nTiming:  \nContext:  \nModifying or Exacerbating Factors:  \nAssociated Signs and Symptoms:  \n2 A PRIMER OF REIMBURSEMENT, BILLING, AND CODING:  \n\n| PAST MEDICAL HISTORY\u003Cbr>FAMILY MEDICAL HISTORY\u003Cbr>Diseases, conditions, illnesses by specific blood relatives: Specific to patient condition:\u003Cbr>SOCIAL HISTORY\u003Cbr>Marital status: |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| \u003Cbr>House location and dwelling:\u003Cbr>Family composition:\u003Cbr>Employment status:\u003Cbr>Insurance status:\u003Cbr>Education:\u003Cbr>Social Coping\u003Cbr>Patient coping:\u003Cbr>\u003Cbr>HABITS\u003Cbr>Tobacco use: Yes 􀂽 No 􀂽 None – distant history and when d/c’d:\u003Cbr>|  |  |  |  |  |  |\n| Alcohol use: | Yes | 􀂽 | No | 􀂽 | None | – distant history and when d/c’d: |\n| Recreational drug use: | Yes | 􀂽 | No | 􀂽 | None | – distant history and when d/c’d: |\n| Illicit Medication use: | Yes | 􀂽 | No | 􀂽 | None | – distant history and when d/c’d: |\n\nESSENTIAL INFORMATION FOR THE HOSPICE  \nAND PALLIATIVE ADVANCED PRACTICE REGISTERED NURSE 3  \nfailure of them:  \n(circle or underline symptoms that are present)  \nPALLIATIVE CARE PAIN  \nPain or Symptom History:  \nPain or Symptom Description:  \nPain or symptom intensity (0-10): Interference with daily life (0-10):  \nWorst it's been in last  \nBest in the last two weeks (0-10):  \nAND SYMPTOM REVIEW  \ntwo weeks (0-10):  \nMedications used and success or  \nPALLIATIVE REVIEW OF SYSTEMS  \nConstitutional: Denies 􀂽 Anorexia 􀂽 Drowsiness 􀂽 Fatigue 􀂽 Fever 􀂽 Weight Loss  \nEyes: Denies 􀂽 Dry eyes 􀂽 Excessive tearing  \nEars, Nose, Mouth, Throat: Denies  \nCardiovascular: Denies  \nRespiratory: Denies  \nGastrointestinal: Denies  \n􀂽  \n􀂽  \n􀂽  \n􀂽  \nSecretions 􀂽 Xerostomia Chest pain 􀂽 LE swelling Dyspnea 􀂽 Cough  \nNausea 􀂽 Vomiting 􀂽 Abdominal pain  \n􀂽  \nConstipation  \n􀂽  \nDiarrhea  \nGenitourinary: Denies 􀂽 Urinary retention 􀂽 Urinary incontinence  \nMusculoskeletal: Denies 􀂽 Bone pain 􀂽 Joint pain 􀂽 Muscle pain  \nSkin: Denies 􀂽 Pruritus 􀂽 Decubitus ulcers 􀂽 Dry skin 􀂽 Rash  \nNeurological: Denies 􀂽 Delirium 􀂽 Agitation 􀂽 Sedation  \nPsychiatric: Denies 􀂽 Anxiety 􀂽 Depressed mood 􀂽 Hallucinations  \nEndocrine: Denies 􀂽 Steroid side effects 􀂽 Cold/heat intolerance  \nAllergic/Immunologic: Denies 􀂽 Immunosuppression 􀂽 Neutropenia  \nHematological/Lymphatic: Denies 􀂽 Bruising 􀂽 Bleeding 􀂽 Lymphedema 􀂽 Lymphadenopathy All other systems reviewed and are negative.  \n4 A PRIMER OF REIMBURSEMENT, BILLING, AND CODING:  \nPALLIATIVE REVIEW OF ADVANCED DIRECTIVES  \nSurrogate Decision-Maker:  \nLocation of Surrogate Decision-Maker Document: Durable Power of Attorney:  \nAdvanced Directives/Living Wills:  \nLocation of Advanced Directives/Living Wills:  \nAttitude towards place of death: home 􀂽 other:  \nFuneral arrangements/wishes:  \nINFORMATION SHARING  \nPatient's awareness of illness:  \n® Serious  \nInformation preferences:  \nFamily awareness of illness:  \n® Serious  \n®  \n®  \n®  \n®  \n® Terminal Not life-threatening ® Not serious Unsure ® Fully involved Leave to ","cbCainpgDdwpYnEk","https://ap.wps.com/l/cbCainpgDdwpYnEk","pdf",157942,6,"English","# Name and Admission Details\n## History (Elements)\n## Palliative Care Pain and Symptom Review\n## Palliative Review of Systems\n## Palliative Review of Advanced Directives\n## Information Sharing and Resuscitation Status\n## Spiritual History\n## Objective/Physical Exam","[{\"question\":\"What patient and admission fields are included in the template?\",\"answer\":\"The template requests patient name, medical record number, date of birth, admission date into the care setting, and details for admitting physician and relevant clinicians. It also includes the reason for consultation and the date of evaluation or visit.\"},{\"question\":\"How does the template structure symptom and pain documentation?\",\"answer\":\"It provides a symptom review section covering location, quality, severity, duration, timing, context, modifying or exacerbating factors, and associated signs and symptoms. For pain, it includes pain or symptom history, description, intensity scoring (0–10), interference with daily life (0–10), and worst/best levels over the last two weeks.\"},{\"question\":\"Which end-of-life planning and treatment-limitation elements are documented?\",\"answer\":\"It collects surrogate decision-maker information, locations of advance directive documents, attitudes toward place of death, funeral wishes, and information sharing preferences. It also captures resuscitation status elements such as no chest compressions, no defibrillation/electrocardioversion, and other life-sustaining treatment limitations, referencing common POLST/MOLST-style orders.\"}]","Sample Palliative Care Consultation/Evaluation Template - Hospice and Palliative APRN Essential Information | PDF"]