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Registered Nurse
30-45 minutes

Detailed Hospice Documentation Records

The Comprehensive Hospice Documentation Notes template by s10.ai is a vital resource for hospice nurses and palliative care specialists, designed to enhance detailed patient record-keeping, including identification, care preferences, and symptom management strategies. This template ensures meticulous documentation of all facets of hospice care, encompassing legal and compliance requirements. By adopting this template, clinicians can deliver personalized, compassionate care that honors patient wishes and facilitates effective communication with family members. It is especially beneficial for maintaining compliance with state regulations and ensuring seamless coordination within the hospice care team.

4,885 uses
5/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

Patient Identification and Contact Information:
Patient Name: [Enter patient’s full legal name]
DOB: [Enter patient’s date of birth]
Medical Record Number: [Enter medical record number]
Primary Care Physician: [Enter physician’s full name] (Contact: [Enter physician’s phone number], [Enter physician’s email address])
Hospice Nurse: [Enter hospice nurse’s full name and credentials] (Contact: [Enter nurse’s phone number], [Enter nurse’s email address])
Emergency Contact: [Enter full name of emergency contact and relationship to patient], Contact: [Enter emergency contact’s phone number]
Limits of Care and Assistance Needs:
[Enter patient’s functional support needs, specific interventions declined, and preferences regarding care setting]
(Write in full sentences describing the level of physical assistance required, such as mobility support, meal assistance, or repositioning frequency. Include clear language around declined interventions such as IV fluids, feeding tubes, hospital transfers, or mechanical ventilation. State patient preference for location of care and philosophy of care such as comfort-focused care.)
Advance Directives and Care Preferences:
Advance Directive on file, last updated: [Enter date of last update]. POLST form signed, indicating [Enter POLST details such as DNR, DNI, etc.]. The patient requests [Enter patient’s preferred symptom management strategies, e.g., oral pain relief, sedation parameters]. Prefers to [Enter preferred care setting or family presence details].
Spiritual support: [Enter spiritual or religious preferences, including faith representative visits or rituals] (only include if applicable).
Care Team Roles and Responsibilities:
[Enter assigned roles and communication responsibilities for each member of the hospice care team and family]
(Include the names and responsibilities of medical decision-makers, medication managers, visit frequency of team members, and who is designated to receive family updates. Write this in full sentences, mirroring the format and tone of the example.)
Symptom and Pain Management Plan:
Current pain level: [Enter self-reported or observed pain level] as reported by the patient. Medication plan:
- [Enter medication name, dose, route, and frequency for pain management]
- [Enter medication name, dose, route, and frequency for anxiety management]
- [Enter any baseline or standing medications]
- Non-medication approaches: [Enter any non-pharmacological methods used, such as warm compresses, massage, guided breathing]
Emergency and Catastrophic Orders:
In the event of rapid decline, administer pre-prepared comfort medications:
- [Enter emergency medication and dose for distress]
- [Enter medication and dose for agitation]
- [Enter medication and dose for secretion management]
If unresponsive and in distress, reposition for comfort and ensure family presence. No hospital transfers or resuscitative measures per patient’s directive.
Family and Caregiver Communication Plan:
[Enter date of most recent family meeting]. [Enter name and relationship of caregiver] informed of current care plan and emergency protocols. [Enter name] to receive [Enter update frequency] via [Enter preferred method]. If significant changes occur, family will be notified [Enter timing of notification].
(Ensure this paragraph mirrors the example structure with dates, names, methods, and trigger events for communication.)
Legal and Compliance Documentation:
Signed DNR order on file – dated [Enter date].
Power of attorney assigned to [Enter name of assigned POA], confirmed by legal documentation.
Insurance: [Enter insurance provider and status of hospice benefit]
All documents reviewed and compliant with state hospice regulations. Next review scheduled for [Enter review date].
Sample Clinical Note

Example of completed documentation using this template

Patient Identification and Contact Information:  
Patient Name: John Doe  
DOB: 15 March 1945  
Medical Record Number: 123456789  
Primary Care Physician: Dr. Emily Smith (Contact: 01234 567890, emily.smith@hospital.org)  
Hospice Nurse: Sarah Johnson, RN (Contact: 09876 543210, sarah.johnson@hospice.org)  
Emergency Contact: Jane Doe, spouse, Contact: 01234 098765  
Limits of Care and Assistance Needs:  
John needs help with mobility and meal preparation. He has refused interventions like IV fluids and mechanical ventilation. He prefers home care with an emphasis on comfort and quality of life.  
Advance Directives and Care Preferences:  
Advance Directive on file, last updated: 1 October 2024. POLST form signed, indicating DNR and DNI. The patient requests oral pain relief and prefers family presence at home. Spiritual support includes weekly visits from a local pastor.  
Care Team Roles and Responsibilities:  
Dr. Emily Smith is the medical decision-maker. Sarah Johnson, RN, manages medications and visits twice weekly. Jane Doe receives family updates and is informed of any changes.  
Symptom and Pain Management Plan:  
Current pain level: 4/10 as reported by the patient. Medication plan:  
- Morphine 10mg, oral, every 4 hours for pain management  
- Lorazepam 1mg, oral, twice daily for anxiety management  
- Lisinopril 10mg, oral, daily  
- Non-medication approaches: warm compresses and guided breathing exercises  
Emergency and Catastrophic Orders:  
In the event of rapid decline, administer pre-prepared comfort medications:  
- Morphine 20mg for distress  
- Midazolam 5mg for agitation  
- Glycopyrrolate 0.2mg for secretion management  
If unresponsive and in distress, reposition for comfort and ensure family presence. No hospital transfers or resuscitative measures per patient’s directive.  
Family and Caregiver Communication Plan:  
Most recent family meeting: 25 October 2024. Jane Doe, spouse, informed of current care plan and emergency protocols. Jane to receive weekly updates via email. If significant changes occur, family will be notified within 24 hours.  
Legal and Compliance Documentation:  
Signed DNR order on file – dated 1 September 2024.  
Power of attorney assigned to Jane Doe, confirmed by legal documentation.  
Insurance: Medicare, hospice benefit active  
All documents reviewed and compliant with state hospice regulations. Next review scheduled for 1 December 2024.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template for Patient Identification and Contact Information is designed to streamline hospice care documentation, ensuring all critical patient data is easily accessible and up-to-date. By incorporating high-search healthcare keywords, this template facilitates efficient communication among healthcare providers, enhancing patient care coordination. Clinicians can effortlessly document patient demographics, limits of care, advance directives, and care preferences, ensuring alignment with the patient's wishes. The template also includes sections for symptom and pain management plans, emergency orders, and family communication strategies, promoting a holistic approach to patient care. Legal and compliance documentation is seamlessly integrated, ensuring adherence to state hospice regulations. Adopt this template to optimize your hospice care workflow, improve patient outcomes, and ensure comprehensive, patient-centered care.
Frequently Asked Questions

Common questions about this template and its usage

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Detailed Hospice Documentation Records