Part 1: Patient Information
Patient name: ________________________________
Patient account #: _____________________________
Diagnosis: ___________________________________
Date of admission: _____________________________
- How are patient's wishes known?
- Patient cognitive/verbal ____
- Advance health care directive ____
- Patient's previous request _____
- Who is the decision-maker?
- Patient ____
- Parents (if minor) ____
- Proxy (specify) _________________________________
- Conference scheduled?
- Yes ____
- No ____
- If yes, proceed to Part 2; if no, explain: _______________________________________
Part 2: Conference Proceedings
Conference facilitator: ____________________________
Conference date & time: __________________
Patient present: Yes ____ No ____
Attending/primary treating physician present: Yes ____ No ____
Health care team members (list name and role):
___________________________ __________________________
___________________________ __________________________
___________________________ __________________________
___________________________ __________________________
___________________________ __________________________
Family members (list name and relation):
___________________________ __________________________
___________________________ __________________________
___________________________ __________________________
___________________________ __________________________
___________________________ __________________________
Issues to be considered (check those addressed)
____ Patient's expressed wishes/values
____ Patient/family satisfaction with current care plan
____ Code Status
____ Patient/family desires or expectations
____ Treatment options and goals of care
____ Pain/symptom mgt
____ Psychosocial and spiritual issues
____ Transition or discharge plan
____ Other
Discussion, outcomes, and follow-up:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Record updated to reflect outcomes of conference:
Date: ____________
Initials: ________
Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes.