Center to Advance Palliative Care

Hi,

I'm not aware of specific requirements for palliative care team meeting documentation... if someone is, please let us know.

But, IDT involvement in the assessment and care provided are a huge part of the quality imperative for palliative care. And, as a general rule, if it's not documented, it didn't happen.

A few recommendations:

(1) Documentation requirements are often a local issue (based on hospital policies)... so checking with your hospital is key.

(2) Minimal documentation would be a listing of all the patients discussed at a meeting and all those in attendance.

(3) Confidentiality is a major focus: our hospital has all the attendees at our meeting sign in at each meeting with their signature attesting that all the patient info discussed at the meeting will be held confidentially.

(4) A record of the team's recommendations should be documented somewhere... typically in a formal consult note back to the referring clinician. For billing, this is required. This then becomes part of the official medical record.

(5) From a program growth perspective, the more pc has their notes, thinking, and expertise seen by other clinicians, the better. To the extent that teams are able, publicizing their sophisticated and compassionate discussions and recommendations to other clinicians in the medical center is a great thing.

Best,
Mike Rabow, MD
Associate Director, UCSF Palliative Care Leadership Center.