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CAPC Palliative Care Discussion Forum
National Quality Forum Framework and Guidelines

In Reply To: team documentation
Next Reply: Re:Re:team documentation
Previous Message: Re:team documentation

Post Re:team documentation
Author: dianeemeier [CAPC Faculty]
Date: Oct 17, 2007 11:08 am
The spirit and intent of the Guidelines is to have genuine interdisciplinary assessment and recommednations and to have the charting relect that process. Even for team members who are not billing (chaplaincy, social work, RN), the chart should reflect your role, assessment, and recommendations, as well as documentation of who you discussed your recommendations with. These notes can be part of a team template note or be part of the regular standard progress note. The note should be headed by "Palliative Care Chaplain visit" for example.
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Re:Re:team documentation (by dianeemeier on 10/17/2007)
PS there are standardized template progress notes available on the capc website as well as in the capc guide that can be modified or changed to fit each individual institution's needs.

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