SICU Palliative Care Assessment - New Jersey Medical School

University of Medicine & Dentistry of New Jersey: SICU Palliative Care Assessment

A single page palliative care assessment form completed by a member of the Family Support Team after interviewing the nurse, resident or attending physician, within 24 hours of the patience admittance to the Intensive Care Unit.

Clinical Care Tools - Clinical Assessment Tool

University of Medicine and Dentistry of New Jersey
150 Bergen Street
Newark, New Jersey 07103-4300

Anne Mosenthal, M.D.
Director, SICU

How the grantee used this instrument:
The palliative care assessment form is to be filled out within 24 hours of admittance. It evaluates the patient in the area of family involvement, pain assessment, and symptom assessment by the nurse and the physician.

care plan, pain assessment, symptom management, health status, protocols, continuity of care, advance directives

To use this tool:
You may print and copy for your own use from this site. Please credit the source.

Developed specifically for this project by the project team.

To view this tool:

Comprehensive SICU Plan > 1page PDF
(Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.)

Posted: July 2006

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Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families.

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