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.

Free 30-day trial. A card is added at signup on Stripe's checkout page; nothing is charged until the 30 days end. Then A$199 + GST per clinician per month.

Spoken in the inpatient unit

Day five of a symptom admission, with discharge home under discussion. The patient is synthetic.

Spoken at the bedside Ambient capture

"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."

Review note Symptom review, day 5 · Demo patient · 81 · Bed 6
Ready to sign
Symptoms

Day 5. Background morphine holding overnight. Two breakthrough doses in 24 hours. Nausea settled on regular metoclopramide. Bowels opened on the aperient.

Sedation and toxicity

Drowsy through the morning, rousable to voice. No myoclonus. No nocturnal confusion.

Goals of care

Home is his preferred place of care, discussed with him and his daughter. Declines readmission for intravenous antibiotics. Accepts a hospital bed at home.

Plan
  • 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
Synthetic demo patient.
GP letterDrafted Discharge summaryQueued Billing3 items

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

Draft The review noteThe overnight symptom picture, the background opioid and the breakthrough doses used, the antiemetic and bowel regimen, the sedation level and any myoclonus.
Draft The family and carer updateFor the family: what is happening, which medicine is for which symptom, who to ring after hours.
Draft The community summaryFor the general practitioner and the visiting nurses: the doses in milligrams, the anticipatory medicines charted, the equipment ordered and the ceiling of treatment.

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.

Start the free trial

Free 30-day trial. Create an account in the iPhone app or at app.aurii.com.au/signup. A card is added at signup on Stripe's checkout page; nothing is charged until the 30 days end.

hello@aurii.com.au