Center to Advance Palliative Care

Each team member charts in the manner of their discipline. Our PC physician charts in the phsycian progress note. My nursing note is electronic in the Progress Notes with the title Palliative Care Nurse Note.

I chart using SBAR: situation, background, assessment and recommendations. I include the headings in my charting until everyone becomes familiar with this tool.

I see paitents at the request of other staff and therefore don't require a physician order. I also communicate face-to-face with medical residents, discussing patient problems and appropriate treatment options -- including referrals for PC team consults.