PivotChart

Step 1 — Patient Information

Enter patient demographics and insurance information.

Patient Demographics

First Name *

Last Name *

Middle Initial

Date of Birth *

Gender *

Preferred Language

Medicare MBI

Primary Insurance

Address & Contact

Street Address *

City *

State *

ZIP *

Phone *

Email

Emergency Contact / Healthcare Proxy

Proxy Name *

Relationship

Proxy Phone *

Proxy Email

Step 1 of 4

Step 2 — Diagnosis & Goals of Care

Document the serious illness, prognosis, and patient's goals and values.

Primary Diagnosis

Primary Serious Illness *

ICD-10-CM Code

Related / Comorbid Diagnoses

Prognosis (if known)

Months to years

6–12 months

3–6 months

Weeks to months

Prognosis uncertain

Referral Source

Hospital / Inpatient

Primary Care Physician

Oncologist / Specialist

Self-referral / Family

Skilled Nursing Facility

Goals of Care Conversation

Patient's Stated Goals *

Treatment Preferences

Curative + comfort (concurrent)

Disease-modifying treatment

Comfort-focused only

Goals not yet established

Advance Directive / POLST Status

✅ On file

In progress

None — discuss at first visit

Key Symptom Burden (check all present)

Pain

Dyspnea

Fatigue

Nausea

Anxiety / Depression

Insomnia

Constipation

Anorexia

Attending Physician

Referring / Attending Physician *

Physician NPI

Admission Date *

Step 2 of 4

Step 3 — Palliative Care Team

Assign the interdisciplinary palliative care team and schedule initial consultations.

Team Assignment

Palliative Care RN / APRN *

Palliative Care Physician / MD

Social Worker

Chaplain / Spiritual Care

Initial Consultation Schedule

Initial RN Assessment Date *

Physician Consultation Date

Social Work Assessment Date

Goals of Care Meeting Date

Visit Frequency Plan

RN Visit Frequency

Social Work Frequency

Phone Check-in Frequency

Step 3 of 4

Step 4 — Review & Complete Admission

Confirm all information and create the patient record.

✅ Review the checklist below, then click Complete Admission to create the patient record in Medplum.

Admission Checklist

Patient demographics — Name, DOB, address, insurance

Primary diagnosis — Serious illness documented

Goals of care — Patient's values and preferences documented

Treatment preferences — Curative vs comfort care noted

Care team assigned — RN and at least one other discipline

Advance directive / POLST — Status documented

Initial consultation scheduled

Auto-Generated After Admission

💛Goals of Care form — opened for completion at first visit

📋Initial Palliative Care Assessment — due at first consultation

💊Symptom Management plan — due within 5 days

Step 4 of 4

🌿 New Palliative Care Admission

Step 1 — Patient Information

Step 2 — Diagnosis & Goals of Care

Step 3 — Palliative Care Team

Step 4 — Review & Complete Admission