Background     Documentation of the consultation serves to:  a) communicate your findings, b) document the service you provided, and c) support your coding and billing activity. In Fast Fact #266, the basic principles of consultation etiquette were reviewed as they apply to palliative care clinicians. Fast Fact #48 provides guidance on billing within the scope of palliative care. This Fast Fact reviews key elements of the palliative care consultation note.

1)  Reason for consultation      “I was asked to see this 87-year-old man with X (primary medical illness) for problems related to shortness of breath and setting appropriate clinically goals-of-care by Dr. Bligh.”  An older etiquette form that is appreciated is to begin the consultation note with the phrase: “Thank you for asking me to see this…” 

2) Summarize the case, including your activities “I have reviewed the medical record and the chest radiographs, interviewed the patient and family, and examined the patient. The following aspects are pertinent…”  

• Pertinent history of presenting illness, relevant comorbidities, and past medical history.
• Pertinent social/family/spiritual History.
• Pertinent medications, PRN usage, allergies, and main medication side effects.
• Pertinent examination findings.
• Pertinent lab/x-ray/pathology.
• Prognosis/advance care planning/goal setting information.

3)  Your assessment     Clearly and prominently indicate your assessment. This is where those who want to know “the bottom line” will look first. It is common practice in some institutions to put your assessment and recommendations at the very top of the note for readability. Encapsulate the case from your point of view. Avoid copying and pasting boiler-plate first-line sentence reviews of the patient from other notes.  Your assessment should be as concise as possible and unique; however, it should contain adequate accounting of your medical decision making, particularly if your discussion could be surprising or unfamiliar to other clinicians (e.g., hospice eligibility in ‘borderline’ cases, opioid hyperalgesia).  

• “This 87-year-old man has dyspnea due to a combination of COPD and metastatic adenocarcinoma of the lung. He understands his diagnosis and that his prognosis could be limited to months. He and his wife are clear would like to receive comfort-focused care at home. They would like no heroic or extraordinary measures used to keep him alive. They agree to a hospice plan of care.” 

4) Recommendations     Number, bullet, and/or bold your recommendations; don’t bury them in a dense paragraph. Be as specific as possible with recommendations and avoid vague statements like “Start morphine for dyspnea.” 

1. Initiate oral morphine 5 mg po q 1h prn to relieve dyspnea or respiratory distress.
2. Initiate dexamethasone 8 mg orally q am to diminish inflammation and add to relief of dyspnea.
3. Enter a DNR order in the chart and give the patient documentation to take with him at discharge.
4. Refer the patient to Pershing Hospice which serves the area where he lives. Their telephone number is 111-222-2222. We would be happy to arrange this if you would like.

5)  Closure      Indicate with whom you have discussed the recommendations and your plan for follow-up. Conclude with the conventional etiquette.  

• “I have discussed these recommendations with Dr. Bligh who concurs. Further, I have discussed my findings with the housestaff, nursing and social work staff caring for this gentleman.” 
• “Dr. Bligh has asked us to continue to follow this patient during his hospitalization to supervise titration of morphine and to continue to provide counseling and information. If you need us, it is best to contact our nurse, Betty Blythe, RN at 444-4444” 
• “Thank you for permitting us to participate in the care of this patient.” 

6)  Signature     Clearly indicate your name and a way that the service can contact you.  

7)  Coding and billing     For coding and billing purposes, if you are using time to justify the level of coding, it is the total amount of time you spent in the patient’s care that day (see Fast Fact #48). That can include the amount of time you spent reviewing the electronic medical record and documenting. 

• “I spent a total of 90 minutes of time involved in this consultation today. This included time spent reviewing the electronic medical record, collaborating with referring clinicians, face to face evaluation and counseling of the patient their family, and post-visit care coordination.” 

References 

1. Campbell M, Dahlin C. Advanced practice palliative nursing: a guide to practice and business issues. Hospice and Palliative Nurses Association; Pittsburgh, PA: 2008. Available from: http://www.hpna.org/Item_Details.aspx?ItemNo=978-1-934654-05-7.
2. Buppert C. Billing for Nurse Practitioner Service — Update 2007: Guidelines for NPs, Physicians, Employers, and Insurers. Medscape Nurses.
3. von Gunten CF, Ferris FD, Kirschner C, Emanuel LL. Coding and reimbursement mechanisms for physician services in hospice and palliative care. J Palliat Med. 2000; 3:157-64.
4. Billing and Coding E-Learning Course. CAPC Campus On-Line. Center to Advance Palliative Care. Billing and Coding – Tools and Resources – CAPC | Center to Advance Palliative Care. Last accessed September 16, 2025.

Authors’ Affiliations:  VP for Medical Affairs, Hospice & Palliative Care, Kobacker House, OhioHealth, Columbus, OH (CvG); Medical College of Wisconsin, Milwaukee, WI (DEW).
Version History:  First published July 2013. Re-copy-edited in September 2015. Reviewed and updated again in September 2025.
Conflicts of Interest: None to report.