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Documentation should include observation, measurable data not just conclusions/opinion. Also all clinical information and indicators of decline must be in the recertification documentation to include scores/scales and comparisons to the last recert or admission.

The narrative summary should include objective data or metrics, such as height, weight, body mass index, mid-arm circumference, Karnofsky Performance Score (KPS), Palliative Performance Score (PPS), Functional Assessment Staging Scale (FAST), New York Heart Association class (NYHA) and pertinent diagnostic test results

Charting hospice decline involves systematically documenting changes in the patients condition demonstrating a trajectory towards end-of-life. This includes: Physical Symptoms: Note any new symptoms or the worsening of existing ones, such as increased pain, nausea, or respiratory distress.

It is therefore important to document each persons own wishes and needs, but also to ensure that there is ongoing discussion of these aspects, as it can be difficult to make predictive decisions regarding ones own death.

Emotional and spiritual support: This is perhaps one of the most important responsibilities of a hospice nurse. They are tasked with the duty of providing compassion and kindness to the dying patients. Not just patients, but hospice nurses also provide psychosocial support to friends and family of patients.

Documentation of medical complications within the previous 12 months, in the context of progressive clinical decline, will help support eligibility for hospice care. the criteria, but may still be eligible for hospice care due to comorbidities or rapid functional decline.

The Interdisciplinary Group (IDG) is the team responsible for the holistic care of the hospice beneficiary. It is this team which is responsible for development and review of the beneficiarys plan of care.

Hospice care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. At some point, it may not be possible to cure a serious illness, or a patient may choose not to undergo certain treatments. Hospice is designed for this situation.

Negative charting demonstrates that we are noticing and treating those symptoms that are present at the terminal phase. of ones life. We know they are there: seek them out, collaborate with your fellow team members about them; document. their presence, and their persistence.

For instance, audits, deficiencies, and legal actions are just a few of the consequences of poor documentation. Another important consideration is hospice documentation supports the patients eligibility for admission and recertification to hospice. Therefore, your documentation should tell the patients story.