Hospice recertification is a crucial step in which the registered nurse case manager can help make the case for continued hospice eligibility. May I encourage my fellow hospice nurses to use a template to ensure your recertification visits are consistent and that you are leading early in the documentation portion regarding what declines have occurred since admission and last recertification?
Some nurses dread doing a recertification visit as much as they dread an admission. They can be challenging at times. I would encourage you to educate your families on the benefits of journaling their caregiver activities, especially incidents of decline, to help you catch every negative event and use a layout like the one below for your records. I find using negative-based vs. positive-based language works best, such as disoriented x3 vs. AOX 1 or oriented to self only and unable to ambulate without the use of a walker vs. ambulates with a walker.
To make IDG discussions and notes easier, please include at the top of the note that it is a RECERTIFICATION NARRATIVE and whether this is the first, second, and so on recert.
Age Gender “on service for” Primary DX who desires to be on hospice services for comfort and does not want further hospitalizations and further aggressive treatment.
Three Related DX and three unrelated DX
SOC Date, SOC Height, Weight, BMI, RMAC PPS, FAST, etc., and what brought the patient onto hospice in the first place.
RECERT DATE, RECERT Height, Weight, BMI, RMAC PPS, FAST
Declines since _______ (admission date or last recertification date):
