Documenting a palliative care review
aurii drafts the review note, the family and carer update and the summary to the GP and the community nursing service from one spoken review.
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Spoken in the inpatient unit
Day five of a symptom admission, with discharge home under discussion. The patient is synthetic.
"Day five. The background morphine held overnight, two breakthrough doses in twenty-four hours."
"Nausea settled once the metoclopramide went regular, and the bowels opened on the aperient."
"Drowsy through the morning but rousable, no myoclonus, no confusion overnight."
"He and his daughter want him home. No readmission for antibiotics, and he will accept a hospital bed and a syringe driver."
"Subcutaneous infusion if he cannot swallow, anticipatory medicines for pain, breathlessness, nausea and secretions, community nursing in two days."
"Daughter update, and a summary to the GP and community nurses with the doses and the ceiling of treatment."
Day 5. Background morphine holding overnight. Two breakthrough doses in 24 hours. Nausea settled on regular metoclopramide. Bowels opened on the aperient.
Drowsy through the morning, rousable to voice. No myoclonus. No nocturnal confusion.
Home is his preferred place of care, discussed with him and his daughter. Declines readmission for intravenous antibiotics. Accepts a hospital bed at home.
- Subcutaneous infusion if swallowing fails
- Anticipatory medicines for pain, breathlessness, nausea and secretions
- Community nursing within two days
- Family update
- Summary to the GP and community palliative service
Illustration of the drafting view.
One review, three readers
aurii drafts the review note, the family update and the summary to the GP and the community nurses from one spoken review. The symptom picture, the background and breakthrough doses, the anticipatory prescribing and the ceiling of treatment reach each document from the same words. The physician signs each.
Documents from one bedside review
Billing items are captured at the bedside against the episode, for your practice to claim. Billing.
Starter templates a palliative care service draws on
A palliative service works from the general starter set: ward and progress notes for the daily entry, the family update, the discharge documents for the community team.
Your letterhead and section order, set once, on every draft. The template set.
Letters to the family, the GP and the community nurses
The family update is written in plain terms. The GP and community nursing summary carries the doses in milligrams, the anticipatory medicines charted and the ceiling of treatment. Both draft from the review and the physician signs both.
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