End of Life Care Plan Template - GPSC
End of Life Care Plan Template - GPSC
End of Life Care Plan Template - GPSC
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CARE PLAN<br />
PATIENT NAME<br />
DOB<br />
PHN<br />
OTHER<br />
ADDRESS<br />
DIAGNOSIS<br />
Main Diagnosis Date <strong>of</strong> Diagnosis Secondary Diagnosis Date <strong>of</strong> Diagnosis<br />
Ht<br />
Wt<br />
Drug / Environmental Allergies<br />
Patient Values/Preferences/Key Goals<br />
Estimated Prognosis<br />
Family/SDM: Values/Preferences/Key concerns<br />
Preferred Place Of Death<br />
CONTACTS / CARE TEAM<br />
Primary Health Provider Phone Primary <strong>Care</strong> Giver<br />
Substitute Decision Maker Phone Key Family Members Phone.<br />
Key Family Members Phone Specialists (Oncologist/Palliative/Other) Phone<br />
Specialists (Oncologist/Palliative/Other) Phone Specialists (Oncologist/Palliative/Other) Phone<br />
Specialists (Oncologist/Palliative/Other) Phone Pharmacist Phone<br />
Home Health Phone Community Nurse(s) Phone<br />
Palliative <strong>Care</strong> Team Phone Home Oxygen Phone<br />
Support Services (Home Support, Hospice Community) Phone Funeral Home Phone<br />
Other Phone Other Phone<br />
CARE PLANNING DOCUMENTATION<br />
DOCUMENT COMPLETED DOCUMENT COMPLETED<br />
Home Health Referral<br />
Palliative <strong>Care</strong> Benefits (Pharmacare) (HLTH 349)<br />
My Voice © workbook<br />
No Cardiopulmonary Resuscitation (HLTH 302.1)<br />
Hospice/Palliative <strong>Care</strong> Registration<br />
Compassionate <strong>Care</strong> Benefits<br />
(SC INS5216B)<br />
Advance Directive/ Greensleeve<br />
Notification <strong>of</strong> Expected Home Death<br />
(HLTH 3987)<br />
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CARE PLAN<br />
PATIENT NAME<br />
DOB<br />
PHN<br />
OTHER<br />
ADDRESS<br />
COLLABORATIVE CARE PLANNING<br />
KEY: 1 = Patient 2 = Family Members 3 = Pr<strong>of</strong>essionals (Please write names<br />
Date Who was present Issues/Outcomes<br />
Followup<br />
(see Key)<br />
ASSESSMENT<br />
ESAS-r<br />
0-Best10-Worst<br />
ASSESSMENT DATES<br />
ESAS-r<br />
0-Best10-Worst<br />
ASSESSMENT DATES<br />
LAB Hb PAIN #1/#2<br />
GFR<br />
TIREDNESS<br />
NAUSEA<br />
DEPRESSION<br />
PPS<br />
OTHER<br />
CONSTIPATION<br />
QUALITY OF<br />
LIFE<br />
ANXIETY<br />
DROWSY<br />
APPETITE<br />
WELL-BEING<br />
DYSPNEA<br />
MEDICATION RECORD<br />
MEDICATION START DOSE FREQ DATE DATE DATE DATE DATE<br />
35 1_EOL_PSP_<strong>Care</strong>_<strong>Plan</strong>_template_GP_V2 3.doc 2 <strong>of</strong> 2