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Specialist In Internal Medicine
5-10 minutes

Terminal Illness Certification

The Certificate of Terminal Illness template from s10.ai is an essential tool for internal medicine specialists and healthcare providers involved in end-of-life care management. This template facilitates the thorough documentation of a patient's terminal diagnosis, accompanying conditions, and pertinent medical history. It also records recent alterations in the patient's living arrangements, cognitive function, medication changes, and physical health indicators. Utilizing this template allows clinicians to deliver a detailed assessment of the patient's condition, aiding in the evaluation of a life expectancy of six months or less. Optimized for seamless integration with s10.ai, this template ensures precise and efficient clinical documentation, encouraging healthcare professionals to adopt and implement it in their practice.

1,206 uses
4.1/5.0
E
Ethan Caldwell
Template Structure

Organized sections for comprehensive clinical documentation

(write a Certificate of Terminal Illness in paragraph format)
[Patient age, pronoun with primary terminal diagnosis] [Pronoun with List secondary diagnoses]. [Pronoun with List of significant past medical conditions] [Description of recent changes in living situation and care needs] [Details of cognitive changes and related symptoms] [Information on recent medication adjustments] [Number of falls in current and previous benefit periods] [Current and previous oral intake measurements in current and previous benefit periods] [Current and previous LMAC and weight measurements in current and previous benefit periods] [Description of any new symptoms developed, leave blank if none] [Current and previous benefit period sleep duration] [Description of activity level and engagement in previously enjoyed activities] [Details of mobility status and assistance required] [Information on ADL independence and assistance required, detailing number out of 6 ADLs they require assistance with, using the format /6 ADLs] [Current Palliative Performance Scale score, stating it is stable if unchanged and comparing it to the previous benefit period if it did change] " It is my judgement that" [Mr or Ms patient's surname] "is terminally ill with a life expectancy of 6 months or less if their condition continues to decline along its usual course."
[Clinician's judgment on life expectancy]
Sample Clinical Note

Example of completed documentation using this template

John Doe, a 78-year-old male, has been diagnosed with advanced pancreatic cancer. He also suffers from chronic obstructive pulmonary disease (COPD) and hypertension. His past medical history includes a myocardial infarction and type 2 diabetes. Recently, John has moved to a hospice facility due to increased care needs. He has experienced significant cognitive decline, exhibiting confusion and memory loss. His medication regimen has been adjusted to manage pain and anxiety. John has had three falls in the current benefit period and two in the previous one. His oral intake has decreased from 50% to 30% of his usual diet. His weight has dropped from 160 lbs to 145 lbs, and his LMAC has decreased from 28 cm to 25 cm. John has developed new symptoms of persistent nausea and vomiting. His sleep duration has reduced from 8 hours to 5 hours per night. He is no longer able to engage in activities he once enjoyed, such as gardening. John requires assistance with mobility and uses a wheelchair. He needs help with 5/6 ADLs, including bathing, dressing, and feeding. His Palliative Performance Scale score has decreased from 40% to 30%, indicating a decline. It is my judgement that Mr. Doe is terminally ill with a life expectancy of 6 months or less if his condition continues to decline along its usual course.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Certificate of Terminal Illness template is an essential tool for healthcare professionals, designed to streamline the documentation process for patients with a terminal diagnosis. This comprehensive template allows clinicians to efficiently record critical patient information, including age, primary and secondary diagnoses, significant past medical conditions, and recent changes in living situations and care needs. It also captures cognitive changes, medication adjustments, fall history, oral intake, LMAC and weight measurements, and any new symptoms. Additionally, it provides a detailed account of sleep duration, activity levels, mobility status, and ADL independence, with a focus on the Palliative Performance Scale score. By utilizing this template, clinicians can ensure accurate and thorough documentation, facilitating better patient care and communication with multidisciplinary teams. This template encourages healthcare providers to adopt a standardized approach, enhancing the quality of end-of-life care and supporting informed clinical judgments on life expectancy.
Frequently Asked Questions

Common questions about this template and its usage

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