Case Review Form Instructions 1. Please identify patient case (or - PDF document

. Case Review Form Instructions 1. Please identify patient case (or process) to present/review at the next ECHO meeting. Select a case that you would like to receive feedback on from the expert ECHO team. If possible, attempt to identify a case that relates to the topic of the day 2. Briefly describe relevant aspects of your case and draft your question(s) for the ECHO team using the Case Review Form 3. It is not necessary to complete every field on the Case Review Form, only those you think are relevant a. Please comply with HIPPA regulations and do not use any Patient Identifiers when submitting cases for review 4. This form should be submitted by noon the day before the next ECHO clinic so that it can be shared with subject matter experts 5. Be prepared to present the case in 20 minutes or less 6. Email your completed form to projectecho@med.unr.edu or fax to (775) 327-5112 Palliative Care Case Presentation Form Date: Presenter: Clinic: New Case: Yes No If “No”, please provide ECHO ID: Please complete as much of this as possible. It is ok to be brief, use abbreviations, etc. This will be a guide for you as you present the case and a tool to refer back to as you manage the case. It will also help Project ECHO Nevada prepare to offer the best recommendations possible. PLEASE NOTE: That Project ECHO Nevada case consultations do NOT create or otherwise establish a provider –patient relationship between any clinician and any patient whose case is being presented in a Project ECHO Nevada PATIENT INFORMATION – Please do not provide Protected Health Information Age: Gender: Male Female Main question or concern you have about this case? Email your completed form to projectecho@med.unr.edu or fax to (775) 327-5112 .

. Check all that apply below to indicate what you hope to know more about for this case: Pain and symptom management Reasonable treatment options and prognosis Communication (e.g. addressing goals of care, code status; delivering bad news; discussing treatment options, etc.) Spiritual, emotional and/or existential distress Advance care planning Ethical issues Other Brief History of Present Illness: Current and Past Medical History and Surgical History: Current Medications and Therapies: Medications and Therapies Used Previously: Allergies/Adverse Drug Responses: Social and Spiritual History: Email your completed form to projectecho@med.unr.edu or fax to (775) 327-5112 .

. Review of Systems: 1. Pain (0-10 scale): /10 or Not assessed in this way 2. (0=none, 1=mild, 2=moderate, 3=severe): Please rank all symptoms. Anxiety Agitation/delirium Depression Drowsiness/fatigue Nausea Vomiting Anorexia Constipation Other Pertinent findings: Path, labs, imaging: Any other information you feel is important: Please be sure you have not included any Protected Health Information. Email your completed form to projectecho@med.unr.edu or fax to (775) 327-5112 .