Medical
Palliative Care Documentation Sample
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Palliative Care Documentation Sample

1
Gather patient case details
2
Evaluate patient's physical condition
3
Assess patient's psychological state
4
Measure patient's nutritional needs
5
Record current prescribed medication
6
Compose a detailed medical history
7
Perform a spiritual examination for the patient if needed
8
Evaluate the needs and conditions of the patient's family or caretakers
9
Approval: Medical Documentation
10
Draft the palliative care plan
11
Compile list of necessary resources and services for the patient
12
Establish goals with patient and family
13
Approval: Care Plan Manager
14
Monitor the progression and effects of the disease
15
Revise patient's care plan regularly based on the current condition
16
Report patient's responses, progress and any changes observed
17
Approval: Clinical Reviewer
18
Decide on the methods to measure the quality of care
19
Document end-of-life decision-making process
20
Record the bereavement process for family and caretakers