Appendix III.

Communication Liaison Note Template and Smart Tool Index:

Communication Liaison Note Template Critical Care Communication Liaison Note Patient: @NAME@ Date of Service: @TD@ DOB: @DOB@ MRN#: @MRN@ CSN: @CSN@ Critical Care Liaison Provider @MECRED@ HPI: @NAME@ is a @AGE@ @SEX@ admitted on @ADMITDT@ for ∗∗∗. Current status: ∗∗∗ vital signs: Critical Care Liaison Provider televisit performed primarily for {Palliative Care Reason for Consult:30421401} Meeting conducted by telephone. The following people (names and relationships to the patient) participated in the meeting: •@MECRED@, Critical Care Liaison Provider •∗∗∗ The following clinical status update was provided to the televisit participants: {Blank single: 19,197:: "As described under ‘current status' above", "∗∗∗"} Markers of progress or setbacks and expected milestones (and what we might do if they are not achieved) {WERE/WERE NOT: 19,253} discussed: ∗∗∗ The patient's functional status, health characteristics, and/or social history prior to admission {WERE/WERE NOT: 19,253} discussed: ∗∗∗ What are the patient's goals as they relate to the current clinical status? {Goals: 304000950} Are the patient's goals realistic in the context of the current clinical status and the patient's status prior to admission? ∗∗∗ Healthcare Proxy/Advance Directive/Consent: Has the healthcare proxy been activated? {HCP Activated: 304009027} Are there existing advanced directives? {Responses: 304009028} Confirm code status: {Code Status: 304000943} Who was code status confirmed with? {Confirmed With: 304000944} SUMMARY, ASSESSMENT, PLAN, NEXT STEPS: ∗∗∗ @telehealthdocumentation@ @TD@ @NOW@ @mecred@ •Symbol Legend •@ symbols flanking text indicates a smart link that will automatically bring information from the patient's chart into the note. •Curly brackets { } indicate a smart list that will present the note author with choices to select from. •A triple asterisk ∗∗∗ indicates a wildcard, a placeholder that must be replaced with free text or deleted.

Smart Tool Index
Smart Link	Output
@NAME@	Patient's full name
@TD@	Today's date
@DOB@	Patient's date of birth
@MRN@	Patient's medical record number
@CSN@	Encounter's contact serial number
@MECRED@	Author's name and credentials
@AGE@	Patient's age
@SEX@	Patient's sex
@ADMITDT@	Date of admission
@VS@	Vital signs
@telehealthdocumentation@	Institution-specific phrase with smart lists to drive telemedicine billing
@NOW@	Current time

Smart List	Options Presented
Palliative care reason for consult: 30421401	Assistance with advance directives Assistance with clarification of goals of care Assistance with withdrawal of life-prolonging measures Facilitation of family care conference Hospice referral or discussion Nonpain symptoms Pain Psychosocial support Spiritual support ∗∗∗
WERE/WERE NOT: 19,253	Were or were not
Goals: 304000950	Recovery to baseline before this admission Recovery to rehabilitation/long-term assisted care (different than baseline before admission) Comfort Unsure ∗∗∗
HCP activated: 304009027	Yes Not indicated There is no health care proxy, consider pursuit of guardianship if indicated ∗∗∗
Responses: 304009028	Yes, directive states: ∗∗∗ There is a copy in the patient's chart HCP has been asked to provide a copy No
Code status: 304000943	Full DNR/DNI Partial Other: ∗∗∗
Confirmed with: 304000944	Patient Health care proxy, name: ∗∗∗ No health care proxy in place, next of kin: ∗∗∗ Not able to confirm code status at this time because of: ∗∗∗
Blank single: 19,197	Generic smart list for end user to develop. Choices appear in note

HCP = health care proxy; DNR = do not resuscitate; DNI = do not intubate.