Purpose: To evaluate a patient with a serious illness using the Palliative Performance Scale.					Citations with documentation. 01.01.02	Sriram & Svirbely 2000
data	enter
Are you evaluating a patient with a serious illness? (Y or N)		:-):-):-)
Is the patient still alive? (Y or N)		:-):-):-)
enter an 'x' in the appropriate column for each question (give only 1 answer per row)
	full	reduced	mainly sit or lie	mainly in bed	bed bound
ambulation						Yes	3
	normal	normal with effort	unable to do normal work	unable to do hobby or light work	unable to do any work
activity						Yes	3
	none	some	significant	extensive
evidence of disease						Yes	3
	full	occasional assistance needed	considerable assistance needed	almost entirely assisted	total care required
self-care						Yes	3
	normal	reduced	a few sips	mouth care only
intake						Yes	3
	full	confusion	drowsy	comatose
consciousness						Yes	3
calculate	result
data complete?	Yes
evaluation appropriate?	Yes	:-):-):-)
Palliative Performance Scale	50
100	No		NA
90	No		50
80	No
70	No
60	No
50	Yes
40	No
30	No
20	No
10	No