Palliative Care for Trauma Patients-Sample EHR Notes

Sample EHR Notes

Pdf Summary

The Trauma/Surgical Critical Care Service (TSICU) held a Family Care Conference to provide updates and discuss the care plan for a patient with acute and prolonged critical care needs. The meeting aimed to establish contact with the family, gather information, and set a clinical course. The attendees included faculty, primary and consultant teams, a surrogate decision-maker, and other individuals. The purpose of the meeting varied depending on whether it was the initial, follow-up, or urgent meeting.<br /><br />During the conference, the hospital course was summarized, including updates on medical issues, injuries, and chronic comorbidities. Prognosis and potential interventions were discussed with input from consultant teams. The goals of care were determined based on a review of the patient's POLST/Advanced Directives, previously expressed end-of-life wishes, and discussions with the surrogate. The shared decision was to continue medical and surgical management without limitations but limit future escalation of supportive care to allow for comfort and dignity during the natural dying process.<br /><br />The code status was reviewed with the family, and it was noted that the patient had a full code status with no limitations, limited code status as discussed, or a DNR/DNI status. The anticipated immediate course of action was to continue medical and surgical management without limitations and meet again in one week. Supportive care would also continue as outlined, with a follow-up meeting scheduled if the clinical condition declines. The possibility of removing life-sustaining interventions according to the family's wishes was also mentioned.<br /><br />The document also stated the amount of time spent during the conference and provided contact information for the Trauma, Critical Care, and Acute Care Surgery team. Additionally, it mentioned that the patient had been identified as having higher palliative care needs based on various criteria, and a family conference was scheduled for a specific date and time.

Keywords

Trauma/Surgical Critical Care Service

Family Care Conference

updates

care plan

patient

acute

prolonged critical care needs

contact

information gathering

clinical course