Serious illness check‑ins

Patient's own rating, 0 (none) to 10 (worst they can imagine).

Lack of energy. Patient's own rating, 0 (none) to 10 (worst they can imagine).

Feeling sleepy. Patient's own rating, 0 (none) to 10 (worst they can imagine).

Patient's own rating, 0 (none) to 10 (worst they can imagine).

Patient's own rating, 0 (none) to 10 (worst they can imagine).

Patient's own rating, 0 (none) to 10 (worst they can imagine).

Sad or depressed mood. Patient's own rating, 0 (none) to 10 (worst they can imagine).

Feeling nervous or worried. Patient's own rating, 0 (none) to 10 (worst they can imagine).

How the patient feels overall. 0 (best) to 10 (worst they can imagine).

One other problem the patient names, in their words, with its 0-10 rating.

True when the patient describes a symptom the protocol treats as urgent. The Agent hands off to a person; it does not assess the symptom.

The patient asked to speak with someone on their care team.

Entered by a clinician only, 0 to 100 in steps of 10. The Agent does not score this. PPS v2 is (c) Victoria Hospice Society; use the official instrument.

What the patient says matters most to them now, in their own words.

Whether the patient says they have chosen a healthcare agent. Record the person on the Member as a Healthcare agent relationship.

• Yes
• No
• Not sure

How the healthcare agent is related to the patient (for example: daughter, spouse). Not the person's name.

The patient's own words, summarized. Not a medical order and not a code status.

• All available treatment
• Some treatment, with limits
• Focus on comfort
• Not sure yet
• Prefers not to say

Whether the patient says an advance directive or similar document exists.

• Yes
• No
• Unknown

The patient would like to talk about these wishes with a clinician.

The patient agrees that their linked caregiver may be told about a check-in.