PALLIATIVE MEDICINE SERVICE HOSPICE ADMISSION
(Bill through UTMB Part B)
DOS: @TD@
CC: GIP Hospice admission for ***
HPI: @ID@ was admitted to GIP Hospice with *** hospice company on @TD@. Prior to that @ID@ was admitted to UTMB acute care on *** for ***. Terminal hospice diagnosis: ***. Prognosis hours to days. Decision made to defer aggressive life prolongation treatment and initiate care concentrating on comfort and symptom management.
Medications: Reviewed MAR dated @TD@
@ALLERGY@
@PMH@
Family History:
@FAMHX@
Social History
@SOCH@
Review Of Systems:
Edmonton Symptom Assessment Scale (ESAS)
Pain ***/10
Fatigue ***/10
Drowsiness ***/10
Nausea ***/10
Depression ***/10
Anxiety ***/10
Dyspnea ***/10
Appetite ***/10
Well-being ***/10
Sleep ***/10
Spiritual Distress: ***
Financial Distress: ***
Medical Team Requesting GIP Hospice Care: {SERVICE TEAMS:30827:::1}
Physical Exam
@VITALSM@
General: NAD, frail, cachetic
Neuro: unresponsive***
HEENT: EOMI, MMM, no pharyngeal edema
Cardiac: RRR, 2+ radial pulses
Respiratory: LCTAB, no wheezing or crackles
Gastrointestinal: +BS x 4, NT/ND, (-) murphy's
Extremities: no pedal edema
Skin: no rashes
% Karnofsky Performance Status
100 Normal, no complaints, no evidence of disease.
90 Able to carry on normal activity, minor signs or symptoms of disease.
80 Normal activity with effort, some signs or symptoms of disease.
70 Cares for self, unable to carry on normal activity or to do active work.
60 Requires occasional assistance, but is able to care for most of his needs.
50 Requires considerable assistance and frequent medical care.
40 Disabled, requires special care and assistance.
30 Severely disabled, hospitalization is indicated although death not imminent.
20 Hospitalization necessary, very sick, active supportive treatment necessary.
10 Moribund, fatal processes progressing rapidly.
0
Labs:
@HGB@
@WBC@
@PLT@
@CREAT@
@Calcium@
@ALB@
@AST1@
@ALT@
I personally reviewed patient's PMHx, social hx, surgical hx, and family hx.
ASSESSMENT/PLAN:
@NAME@ is a @AGE@ @SEX@ admitted to GIP for ***. Patient and family in agreement with transfer to GIP hospice care to focus on comfort care and symptom management.
Pain/Shortness of Breath:
-roxanol 15mg q4h prn
-iv morphine 4mg q4h prn
Terminal secretions:
-scopolamine patch
-robinul 0.2mg iv q6h prn
Constipation:
-dulocolax suppository if no BM in 2 days
Delirium: Terminal in nature
-Delirium precautions: open blinds during day and close at night, ensure visual presence of clock and calendar, provide hearing aides/dentures as appropriate, avoid frequent interruptions during the night
Dispo: If patient stabilizes, will discuss discharge home with hospice. If patient declines, will continue to aggressively manage symptoms under GIP until death occurs in facility.
Please call the Palliative on-call pager at 409-942-6117