Table 6.
Areas of Evaluation and Management Present in Consultation Notes
| N=132 No. (%) in which the code appeared at least once |
|
|---|---|
| Areas Evaluated in Initial Consultation | |
| Marital/Partner Status | 122 (92) |
| Spirituality/Emotional Well-being | 118 (89) |
| Advanced Directive & Code Status | 114 (86) |
| Caregiver/Family Support/Children | 113 (86) |
| Goals of Care | 112 (85) |
| Living Arrangements | 110 (83) |
| Surrogate Identified | 88 (67) |
| Work History | 82 (62) |
| Functional Status | 78 (59) |
| Decisional Capacity | 63 (48) |
| Prognosis Understanding | 59 (45) |
| Hospice | 54 (41) |
| Substance Abuse | 29 (22) |
| Financial | 28 (21) |
| Cultural Background | 28 (21) |
| Education | 10 (8) |
| Symptoms Evaluated in Initial Consultation | |
| Cognitive/Mental Status | 94 (71) |
| Mood | 89 (67) |
| Breathlessness | 87 (66) |
| General Pain | 87 (66) |
| Fatigue | 60 (45) |
| Weight Loss/Dietary Concerns | 44 (33) |
| Grief & Bereavement | 38 (29) |
| Nausea/Vomiting | 37 (28) |
| Sleep Problem | 27 (20) |
| Anorexia | 26 (20) |
| Chest Pain | 23 (17) |
| Constipation | 22 (17) |
| Diarrhea | 20 (15) |
| Dry Mouth | 16 (12) |
| Treatment Recommendation | |
| Counseling: Supportive, Psychodynamic, etc. | 64 (48) |
| Medication: Initiate | 63 (48) |
| Coordinate Care/Family Communication | 57 (43) |
| Coordinate Care/Provider Communication | 54 (41) |
| Arrange Family Meeting | 51 (39) |
| Help with Decision-making | 31 (23) |
| Consult/Referral | 30 (23) |
| Medication Decrease | 25 (19) |
| Cardiac Advanced Therapeutics | 25 (19) |
| Non-cardiac Advanced Therapeutics | 25 (19) |
| Medication Maintained | 24 (18) |
| Spiritual Care | 21 (16) |
| Medication Increase | 13 (10 |
| Treatment Recommendations for Symptoms | |
| Breathlessness | 30 (23) |
| General Pain | 24 (18) |
| Anxiety | 18 (14) |
| Depression | 10 (8) |
| Fatigue | 4 (3) |
| Constipation | 4 (3) |
| Sleep Problem | 4 (3) |
| Cognitive/Mental Status | 4 (3) |
| Anorexia | 3 (2) |
| Dry Mouth | 2 (2) |
| Chest Pain | 1 (1) |
| Nausea/Vomiting | 1 (1) |
| Diarrhea | 1 (1) |
| Advanced Care Planning Interventions | |
| Discuss Hospice Referral | 51 (39) |
| Goals of Care: Weigh & Consider | 50 (38) |
| Discuss Prognosis | 42 (32) |
| Discuss Illness Trajectory | 40 (30) |
| Assist to Identify Surrogate | 17 (13) |