Empassion template
EMPASSION VISIT SUMMARY:
Visit setting:
Primary ICD 10 code:
New or worsening symptoms:
Pain score (0–10):
Is the patient clinically eligible for hospice?
Acuity level:
Was advance care planning discussed?
If so, was documentation uploaded?
Does the patient have any urgent needs to report?
If yes, describe:
Does the patient need any DME?
If yes, what DME is needed?
Does the patient need any medication(s) filled?
If yes, which medication(s)?
Do you have any recommended changes to the patient’s current medication(s)?
Does the patient need any specialist referrals?
Does the patient need home health?
Does the patient need homemaker services?
Does the patient need mail order pharmacy?
Does the patient need meal delivery?
Does the patient need transportation assistance?
Does the patient have other needs not previously covered?
Disenroll patient?
Return patient to Empassion for Palliative Monitoring Program?