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: ________