An example recertification template for hospice eligibility

Published on January 22, 2023

Updated on December 25, 2023

is a crucial step where the registered nurse case manager can help make the case for continued . May I encourage my fellow hospice nurses to start using a template to ensure your recertification visits are consistent and that you are leading on early in the documentation portion as to 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 difficult 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 single negative event and use a layout like the one below for your recerts. 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, be sure to include at the very top of the note that it is a RECERTIFICATION NARRIATIVE and whether this is the 1st, second, and so on recert.

  • Age Gender “on service for” Primary DX who desires to be on 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 , FAST, etc. as well as what brought the patient onto hospice in the first place.
  • Declines since _______ (admission date or last recertification date):
  • Medication changes since
  • changes since
  • Medication Managed by whom
  • Code Status:
  • ADL's (Complete Care, Ambulation, Transfer, Dressing, Bathing, Toileting, Feeding including changes)
  • Intake: Food (% intake, pureed, thin, NPO, including changes)
  • Mobility (full, Walker, transfer x, broad, bed-bound including changes)
  • Activity level (sleeps 90%, naps more, alert, and oriented including changes)
  • Pain (any, what level, controlled or not)
  • Continence
  • MAC (define Right or Left) vs. admission or previous recert
  • PPS (vs admission level)
  • Fast (any dementia, Alzheimer) vs. admission or previous recert
  • Examination by system: Complexion, Neuro including pupils, Cardio, Pulmonary, GI and GU, Skin
  • Short narrative/summary of what is going on.

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