Palliative care progress note example 2026

1. Click ‘Get Form’ to open the palliative care progress note in the editor.
2. Begin by entering the patient’s name and medical record number (MR#) at the top of the form. This ensures that all information is accurately linked to the correct patient.
3. Select the type of visit: Initial Visit, Acute Care, Recertification, or Annual Exam. This helps categorize the patient's care appropriately.
4. Indicate whether advance directives are present by selecting 'Yes' or 'No'. This is crucial for understanding patient preferences.
5. Fill in the Review of Systems (ROS) and History of Present Illness (HPI) sections. Document any recent problems and allergies as necessary.
6. Complete the Functional Status section by assessing basic activities of daily living (ADLs) such as transfers, feeding, bathing, dressing, and grooming. Mark whether assistance is needed.
7. In the Physical Exam/Clinical Data section, provide details on vital signs and general appearance. Ensure all observations are noted accurately.
8. Finally, review your entries for accuracy before signing off on the assessment and plan section. Ensure that both NP/Resident’s Signature and Attending Signature fields are completed.

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