PCHOME Domiciliary & Palliative Clerking Sheet

A. Functional Status

ECOG

Modified Barthel Index

Mobility

Main Caregiver

P – Physical Needs

Acute • Behaviour • Chronic • Prevention

Physical Needs Toolkit

Quick access for general physical assessment and pressure injury risk assessment during home visit.

Pain Score 0–10

Dyspnoea

Nutrition

Symptoms

Pain Nausea/Vomiting Constipation Wound / Pressure injury Braden Poor oral intake Fatigue

Current Acute Issue

Medication Review

Anticipated Complication / Advice Given

Risk Snapshot

Overall Risk

Low

Urgency

Routine

Quick Links

Fast access to HafizCare clinical tools.

C – Care Environment

CARES

Toilet Type

Home Safety

Financial Issue

Caregiver Stress

Equipment / Support

Environment Notes

H – Healthcare Coordination

Follow-up Centre

Specialist Team

ACP Status

Next Appointment

Coordination / Referral Needed

O – Outlook & Emotional Well-being

EMOTION

Mood

Coping

Quality of Life 0–10

Social Isolation

Emotional / Family Notes

M – Meaning & Spirituality

GRACE

Religion / Belief

Spiritual Concern

Goals / Values / Hopes / Fears

E – End-of-Life Planning

PEACE

Goal of Care

Preferred Place of Care

Preferred Place of Death

Family Aware Diagnosis

Unfinished Business / EOL Notes

Assessment & Plan

Problem List

Management Plan

Generated Clerking Summary

Click “Generate Summary” after clerking.