Collects data to create a comprehensive history, including, but not limited to, chief complaint, history of present illness, past medical/surgical history, family history, social history, functional status, immunization history, allergies, and palliative review of systems.

Assesses functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic aspects of care in a systematic and ongoing process while honoring the uniqueness of the patient as a person.

Determines the patient and family’s emotional response and coping in respect to advanced illness, anticipatory grief, complicated grief, depression, anxiety, and delirium (NCP, 2013).

Evaluates the social aspects in the patient’s care, in particular the social well-being, coping skills, educational needs, family dynamics, and goals of each patient and family, as appropriate to the health care setting and the presence of other interdisciplinary team (NCP, 2013). Considers impact on the patient’s health, wellness, and illness, as well as death and dying.

Elicits the patient’s values, preferences, beliefs, expressed needs, and understanding of his or her condition.

Involves the patient, family, and other healthcare providers as appropriate, in holistic data collection.

Identifies barriers (e.g., psychosocial, literacy, language, financial, cultural) to effective communication and makes appropriate adaptations.

Recognizes the impact of personal attitudes, values, and beliefs on palliative care delivery.

Assesses the spiritual/religious/existential realm depending on the patient’s beliefs, including, but not limited to, the meaning of illness, life, and death; a connectedness to self, others, nature, a spiritual being and/or God; a sense of hope/hopelessness; and/or a need for forgiveness, as appropriate to the healthcare setting and the presence of other interdisciplinary team members (NCP, 2013).

Prioritizes data collection based on the patient’s immediate condition, or the anticipated needs of the patient, family, or situation.

Uses appropriate evidence-based assessment techniques, instruments, and tools (e.g., pain scales, functional assessment tools, physical and psychiatric symptom scales, quality-of-life rating scales, prognostic scales).

Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances.

Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use, and dissemination of data and information.

Recognizes patients as the authority on their own health by honoring their care preferences.

Documents relevant data in a retrievable format.

Initiates and interprets diagnostic tests and procedures relevant to the patient’s current status.

Assesses the effectiveness of interactions among patients, family, community, and social systems on health and illness.

Reviews allergies and current medication for maximum effectiveness and possible need for adjustment based on further assessments.

Identifies the goals of care as stated by the patient, surrogate, healthcare proxy, or as documented through advance care planning (NCP, 2013).

Involves and collaborates with the patient, family, interdisciplinary team, and others while formulating expected outcomes to improve quality of life.

Derives culturally, developmentally, and age-appropriate expected outcomes based on goals of care, the diagnoses, and health status.

Considers associated risks, benefits, costs, current scientific evidence, expected trajectory of the condition, and clinical expertise when formulating expected outcomes.

Defines expected outcomes in terms of the patient and family’s goals of care, quality of life, values, culture, and ethical considerations.

Includes a time estimate for attainment of expected outcomes.

Develops expected outcomes that provide direction for continuity of care across care settings, from the period of diagnosis through family bereavement.

Modifies expected outcomes according to situational and status changes of the patient.

Documents expected outcomes as measurable goals.

Identifies expected outcomes that incorporate scientific evidence and are achievable through implementation of evidence-based practices.

Identifies expected outcomes that incorporate cost and clinical effectiveness, patient satisfaction, and continuity and consistency among providers.

Differentiates outcomes that require process interventions from those that require system-level interventions.