Comprehensive Hospice Documentation Narrative Notes Template

The patient has chosen hospice care with s10.ai as the designated provider. At the time of this decision, the patient confirmed a comprehensive understanding of the hospice model, particularly the difference between palliative and curative care, and acknowledged that certain Medicare services would be waived upon election. The hospice election became effective on 1 November 2024, marking the first day of hospice services or a later date chosen by the patient. The attending physician selected by the patient is Dr. Thomas Kelly, whose credentials and contact information are on file. The patient confirmed that this choice was made independently.
Documentation indicates that hospice is responsible for providing nearly all services related to the terminal illness, with exceptions being rare and extraordinary. The patient was also informed about cost-sharing for hospice services and received details about their rights, including the right to request an election statement addendum for services deemed unrelated to the terminal diagnosis. They were provided with information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including their right to immediate advocacy and contact details. The election statement was signed by Jane Doe, the patient or their authorized representative.
An addendum to the election statement titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” was provided by s10.ai. It includes the patient’s name and medical record identifier and outlines the terminal diagnosis along with a list of any conditions present at admission that were deemed unrelated to the terminal illness. For each non-covered item, a written clinical explanation was documented in language understandable to the patient or representative. This explanation included general justification from hospice and encouraged the patient to share the information with other providers.
The addendum referenced relevant clinical guidelines and was issued to inform the patient of services hospice will not cover. The patient was reminded of their right to advocacy. The document was signed on 1 November 2024 by John Doe to acknowledge receipt, not agreement. If the patient or representative declined to sign, the reason was documented. The addendum was formally furnished to the patient on 1 November 2024.
Certification of terminal illness was completed by Dr. Emily Smith, a hospice medical director or IDG physician, no later than two calendar days after the start of hospice services. If a verbal certification was obtained, it was received from Dr. Emily Smith and included a statement that the patient is terminally ill with a life expectancy of six months or less. This verbal certification was documented and signed by hospice staff on 1 November 2024. The written certification includes a detailed physician narrative summarizing clinical findings that support the terminal prognosis, with the narrative appearing directly above the physician’s signature.
The physician attests to composing the narrative based on a review of the medical record or personal examination. The certification also documents the benefit period dates: from 1 November 2024 to 1 May 2025, and includes the physician’s signature and date. For third or subsequent benefit periods, a face-to-face visit occurred on 1 November 2024 conducted by Dr. Emily Smith, who attested in writing to the encounter. If completed by a non-certifying clinician, the findings were relayed to the certifying physician. The attestation appears in a separate, clearly titled section and is signed and dated by the individual who performed the visit.
The plan of care (POC) was developed collaboratively by the interdisciplinary group (IDG) and the attending physician to establish treatment goals and coordinate services in line with the patient's needs. The POC outlines current care objectives such as pain and symptom management, coordination of home visits, psychosocial support, and caregiver education. It was reviewed on 1 November 2024, with the POC covering services from 1 November 2024 to 15 November 2024. POC reviews occur no less frequently than every 15 days, and the most recent review meets this compliance threshold.
To support the terminal prognosis, documentation includes a comprehensive narrative that describes the patient’s current condition, diagnosis, and trajectory of decline. Notable clinical indicators such as weight loss, reduced functional status, ADL dependence, and changes in responsiveness are recorded with quantifiable data where available. The patient’s clinical course reflects increasing need for care and a consistent decline. The narrative avoids vague terminology and instead provides objective descriptions, such as pounds lost, number of hospitalizations, and specific measurement values. These findings collectively support a life expectancy of six months or less.
The patient’s level of care (LOC) is documented as Routine. A change in LOC occurred on 1 November 2024, prompted by increased pain management needs. For Continuous Home Care (CHC), documentation confirms a minimum of 8 hours of combined nursing and aide services within a 24-hour period, with over 50% delivered by an RN or LPN. If Respite care was used, it is confirmed that the patient resides at home and not in a long-term care facility. For General Inpatient Care (GIP), the documentation includes detailed rationale such as uncontrolled symptoms, need for psychosocial monitoring, or inability to manage the patient in a home setting.