Introduction

Hospice care represents a profoundly important chapter in the lives of patients and their families, one marked by compassion, dignity, and comfort. As hospice nurses, we are responsible for this journey through direct care and documenting our observations and interventions. The narratives we craft in our documentation are more than mere records; they are comprehensive accounts that capture the patient's condition, the care provided, and the compassionate essence of hospice philosophy.

Overview of the Importance of Detailed Hospice Nursing Narratives

Detailed hospice nursing narratives are essential for several reasons:

1. Ensuring Continuity of Care: Accurate and comprehensive documentation ensures that all team members are informed about the patient's condition and the care provided. This promotes seamless care transitions and consistent quality of care, whether from one shift to the next or during interdisciplinary team meetings.
2. Supporting Eligibility for Hospice Services: Medicare and other insurers require detailed documentation to justify continued hospice eligibility. Our narratives provide evidence of the patient's ongoing decline in condition, which is crucial for recertification periods.
3. Legal and Ethical Protection: Thorough documentation can protect the patient and the care team legally and ethically. It is a clear record of the care provided, the decisions made, and the patient's responses, which can be critical in disputes or reviews.
4. Enhancing Communication: Detailed narratives improve communication among healthcare providers, patients, and their families. They provide a clear picture of the patient's status and the goals of care, facilitating informed decision-making and coordinated efforts.
5. Reflecting Compassionate Care: Our narratives should reflect the clinical aspects of care and the compassionate, holistic approach that defines hospice care. Documenting moments of emotional support, comfort measures, and patient and family interactions captures the full scope of our role.

Objectives of the Article

This article aims to equip hospice nurses with the knowledge and tools needed to create compelling nursing narratives that meet regulatory requirements, enhance patient care, and reflect the compassionate nature of hospice work. Specifically, this article will:

1. Define the Elements of Effective Narratives: We will explore what constitutes a well-crafted nursing narrative, including its length, content, and structure.
2. Identify Key Documentation Areas: Detailed guidance will be provided on documenting routine visits, PRN visits, triage calls, admissions, recertifications, and various discharges.
3. Highlight the Importance of Negative-Based Wording: The article will explain why negative-based wording is critical in accurately depicting a patient's decline and provide practical examples.
4. Emphasize the Role of Empathy in Documentation: While focusing on the technical aspects of documentation, we will also discuss how to ensure that our narratives convey the compassionate care at the heart of hospice work.

Through this comprehensive guide, we hope to enhance the quality of hospice documentation, ensuring that it meets all necessary criteria while reflecting the profound empathy and dedication that define our profession.

Understanding the Hospice Nursing Narrative

As hospice nurses, our work often transcends the boundaries of typical healthcare roles, requiring a deep commitment to clinical excellence and compassionate care. An essential aspect of our responsibilities involves creating hospice nursing narratives. These narratives serve as the backbone of our documentation, encapsulating the story of each patient's end-of-life journey. They are more than just records; they are critical tools that ensure comprehensive, continuous, and compassionate care.

Definition and Purpose

What is a Hospice Nursing Narrative?

A hospice nursing narrative is a detailed, structured account of a patient's condition, the care provided, and the patient's response to that care. Hospice nurses write these narratives to document various aspects of patient care during each interaction, including routine visits, PRN (as needed) visits, triage calls, admissions, recertifications, and discharges. Each narrative should include observations of the patient's physical and emotional state, any interventions or treatments administered, and interactions with family members or caregivers.

A well-crafted nursing narrative typically includes:

• Patient Observations: Detailed notes on the patient's physical condition, symptoms, cognitive status, and emotional well-being.
• Interventions: Describe the care provided, such as medications administered, comfort measures implemented, and any therapeutic activities.
• Outcomes: The patient's response to the interventions, changes in symptoms, and overall progress or decline.
• Interactions: Notes on conversations with the patient, family members, and other caregivers, highlighting their concerns, preferences, and needs.

Why is it Important?

1. Ensuring Continuity of Care: One of the most critical roles of hospice nursing narratives is to ensure continuity of care. These narratives provide a detailed account that informs all healthcare team members about the patient's current condition, the care given, and the response to that care. This is particularly vital in hospice settings, where multiple caregivers may see patients. Thorough documentation ensures that caregivers understand the patient's status and needs clearly, enabling consistent and seamless care.
2. Supporting Eligibility for Hospice Services: Hospice care is often covered by Medicare and other insurance providers, but this coverage requires proof of the patient's ongoing eligibility. Detailed narratives are essential in demonstrating that the patient continues to meet the criteria for hospice care, showing a clear and documented decline in their condition. This documentation is crucial during recertification periods, ensuring patients receive the necessary care without interruption.
3. Legal and Ethical Protection: Thorough documentation can protect the patient and the healthcare provider. Accurate and comprehensive nursing narratives can provide a clear record of the care provided, the decisions made, and the patient's responses. This can be critical in legal disputes or reviews, offering transparency and accountability.
4. Enhancing Communication: Effective communication is a cornerstone of high-quality healthcare. Detailed nursing narratives improve communication among healthcare providers, patients, and their families. They provide a clear, concise picture of the patient's status and the goals of care, facilitating informed decision-making and coordinated efforts. This is particularly important in hospice care, where the focus is on holistic, patient-centered care that involves the patient's loved ones.
5. Reflecting Compassionate Care: Finally, hospice nursing narratives reflect the compassionate, holistic approach that defines hospice care. While clinical details are crucial, these narratives should also capture care's emotional and psychological aspects. Documenting moments of emotional support, comfort measures, and meaningful interactions with patients and their families helps to portray the full scope of hospice nursing. It highlights the empathetic and personalized care at the heart of our profession.

In essence, hospice nursing narratives are vital tools that support the multifaceted role of hospice nurses. They ensure that our care is informed, consistent, and compassionate, reflecting the high standards of hospice care. By understanding and valuing the importance of these narratives, we can better serve our patients and their families, providing the comfort and dignity they deserve during this profound journey.

Length of the Hospice Nursing Narrative

In hospice care, the nursing narrative serves as a crucial tool for documenting the patient's journey and the care provided. The length of these narratives can vary significantly based on several factors, including the patient's condition's complexity and the visit's type and purpose. Striking the right balance between being concise and comprehensive is essential for adequate documentation.

Factors Determining Length

Complexity of Patient’s Condition

The complexity of a patient's condition is a primary factor influencing the length of the nursing narrative. Detailed documentation is necessary for patients with multiple interrelated health issues to provide a complete picture of their status and care needs. For instance, a patient with advanced cancer and numerous symptoms such as pain, nausea, and difficulty breathing will require more extensive documentation than a patient with fewer, less severe symptoms.

Key elements to include for complex conditions:

• Symptom Description: Detailed observations about symptoms' nature, frequency, and severity.
• Interventions and Responses: Specifics about medications or treatments provided and the patient's response to these interventions.
• Changes Over Time: Notable changes in the patient's condition, whether improvement or decline, to track progression.

Visit Type and Purpose

The type and purpose of the visit also play a significant role in determining the length of the nursing narrative. Different types of visits require varying levels of detail:

1. Routine Visits: Regularly scheduled visits focus on ongoing assessment and management. Documentation should include updates on the patient's current status, new symptoms, and the effectiveness of ongoing treatments.
2. PRN (As Needed) Visits address acute changes or specific concerns. Taking detailed notes on the triggering symptoms, interventions provided, and immediate outcomes is crucial.
3. Triage Calls: When documenting triage calls, include the nature of the call, advice given, and any follow-up actions taken.
4. Admission Visits: Initial assessments need comprehensive documentation of the patient's history, baseline condition, and initial care plan.
5. Recertification Visits: These require evidence of continued eligibility, with detailed descriptions of the patient's decline and supporting assessments.

Best Practices for Narrative Length

Concise yet Comprehensive Documentation

Achieving concise yet comprehensive documentation involves capturing all essential details without unnecessary verbosity. Here are some best practices:

1. Be Specific and Clear: Use clear, specific language to describe symptoms, interventions, and patient responses. Avoid vague terms that can lead to misinterpretation.
2. Focus on Key Information: Highlight the most critical aspects of the patient's condition and care. Include vital signs, symptom changes, interventions, and patient and family interactions.
3. Use Structured Formats: Employ structured formats or templates to ensure consistency and completeness. This can include sections for observations, interventions, outcomes, and care plans.

Examples of Appropriately Detailed Narratives

To illustrate the balance between conciseness and comprehensiveness, consider these examples:

1. Routine Visit Example:
   • Patient Condition: “Patient appears weak and fatigued, reports pain level of 6/10 in lower back.”
   • Interventions: “Administered 5 mg of morphine buccally. Educated family on repositioning techniques.”
   • Outcomes: “Pain reduced to 3/10 within 30 minutes. Patient rested comfortably, no adverse reactions observed.”
   • Plan: “Continue current pain management plan, follow-up in two days.”
2. PRN Visit Example:
   • Triggering Event: “Patient called reporting severe shortness of breath and anxiety.”
   • Interventions: “Administered 2.5 mg of lorazepam sublingually and 2 L/min of oxygen via nasal cannula.”
   • Outcomes: “Breathing improved within 15 minutes, and anxiety reduced. The patient and family were reassured, and emergency contact instructions were reiterated.”
   • Plan: “Increase frequency of oxygen saturation checks, scheduled follow-up visit for the next day.”
3. Admission Visit Example:
   • Baseline Assessment: “Patient admitted with metastatic lung cancer, experiencing constant pain (7/10), weight loss, and difficulty swallowing.”
   • Interventions: “Initiated morphine sulfate 10 mg q4h PRN for pain.”
   • Outcomes: “Initial pain relief achieved, patient able to consume small amounts of liquid.”
   • Plan: “Develop an individualized care plan focusing on pain management, nutritional support, and psychological comfort.”

In summary, the length of a hospice nursing narrative should be tailored to the patient's condition's complexity and the visit's type and purpose. By focusing on critical information and using structured formats, hospice nurses can create narratives that are both concise and comprehensive, ensuring high-quality documentation that supports patient care and compliance.

Key Documentation Areas to Support Continued Hospice Eligibility

In hospice care, meticulous documentation is not just a bureaucratic requirement; it is essential to ensure that patients continue receiving the care they need. Accurate and comprehensive documentation supports the justification for continued hospice eligibility, often scrutinized by Medicare and other insurance providers during recertification periods. Below, we explore key areas that hospice nurses should focus on in their documentation to support ongoing hospice care.

Clinical Documentation

Symptoms and Signs of Decline

Thorough documentation of symptoms and signs of decline is crucial. This includes detailed observations of new or worsening symptoms that indicate a patient's health status decline. Key elements to document include:

• Pain: Note the location, intensity, frequency, and duration of pain, as well as any factors that exacerbate or relieve it. Use pain scales to quantify severity.
• Dyspnea (Shortness of Breath): Record the frequency and triggers of dyspnea and how it affects the patient's daily activities and overall comfort.
• Fatigue and Weakness: Document fatigue and muscle weakness levels, noting any significant changes.
• Nausea and Vomiting: Detail the frequency, triggers, and impact on nutritional intake and hydration.
• Changes in Skin Condition: Record any pressure ulcers, wounds, or other skin conditions, including their size, appearance, and progression.

Medical Interventions and Responses

Documenting medical interventions and the patient's responses to these interventions is essential. This includes:

• Medications: Record all medications administered, including dosages, routes, and frequencies. Note any changes in the medication regimen and the reasons for these changes.
• Symptom Management Techniques: Document other interventions, such as repositioning, oxygen use, and non-pharmacological pain management strategies.
• Responses to Interventions: Detail the patient's response to each intervention, including improvements or adverse reactions.

Functional Decline

ADLs (Activities of Daily Living) Assessment

Assessment of a patient's ability to perform Activities of Daily Living (ADLs) provides a clear picture of their functional status. ADLs include:

• Personal Hygiene: The patient's ability to bathe, groom, and maintain oral hygiene.
• Dressing: The ability to choose appropriate clothing and dress independently.
• Eating: The ability to feed oneself, including using utensils and managing food intake.
• Toileting: The ability to use the toilet independently, including managing incontinence if present.
• Transferring is the ability to move from one position to another, such as from bed to chair, and mobility within the home.

Documenting the patient's level of independence in these areas and any assistance required helps illustrate their functional decline and ongoing need for hospice care.

Cognitive Status

Cognitive decline is often a significant aspect of a patient's overall decline. Key elements to document include:

• Orientation: The patient's awareness of person, place, time, and situation.
• Memory: Short-term and long-term memory capabilities.
• Judgment and Problem-Solving: The ability to make safe and appropriate decisions.
• Communication: Understanding and expressing thoughts, including speech patterns or comprehension changes.

Observations of confusion, disorientation, and other cognitive changes should be documented to provide a comprehensive view of the patient's cognitive decline.

Nutritional Intake

Weight Loss Trends

Weight loss is a significant indicator of decline in hospice patients. Documentation should include:

• Baseline Weight: The patient's weight at the time of admission.
• Weight Changes: Regular updates on weight, noting any significant losses.
• BMI: Calculations of Body Mass Index (BMI) to provide context for weight changes.

Documenting these trends helps demonstrate the patient's nutritional status and the impact of their illness on their overall health.

Nutritional Intake Assessments

Nutritional intake assessments provide insight into the patient's ability to maintain adequate nutrition and hydration. Key elements to document include:

• Food and Fluid Intake: The amount and type of food and fluids consumed, noting any difficulties in eating or drinking.
• Appetite: Changes in appetite, including periods of anorexia or refusal to eat.
• Swallowing Difficulties: Any issues with chewing or swallowing, including the need for modified diets or feeding assistance.

These assessments help to paint a comprehensive picture of the patient's nutritional decline, supporting the need for continued hospice care.

Routine Visits

Routine visits form the backbone of hospice care, allowing for continuous monitoring and management of a patient's condition. These visits provide opportunities to assess the patient's status, manage symptoms, and support the patient and their family. Documenting these visits thoroughly ensures that all aspects of care are captured, promoting continuity and quality of care. Below, we explore essential tips for documenting routine visits, focusing on regular assessments, symptom management, and patient and family interactions.

Documentation Tips

Regular Assessments

Regular assessments during routine visits are crucial for monitoring the patient's ongoing condition and identifying any changes that might require adjustments to the care plan. Effective documentation should include the following:

1. Pain Assessment: Use pain scales (e.g., 0-10) to quantify pain levels and describe the location, quality, and duration of pain.
   • Example: “Patient reports pain level of 5/10, described as sharp and intermittent, located in the lower back.”
2. Physical Examination: Conduct and document a thorough physical examination, noting any new or worsening symptoms, skin integrity, and overall appearance.
   • Example: “No new skin breakdowns noted. Slight swelling in the lower extremities, unchanged from the previous visit.”
3. Functional Status: Evaluate and document the patient's ability to perform Activities of Daily Living (ADLs) and any changes in mobility or independence.
   • Example: “Patient requires assistance with dressing and bathing, able to eat independently but with encouragement.”

Symptom Management

Effective symptom management is a cornerstone of hospice care, ensuring the patient's comfort and quality of life. Documenting symptom management should include:

1. Current Symptoms: Note the presence and severity of current symptoms, such as pain, nausea, dyspnea, fatigue, and anxiety.
   • Example: “Patient experiencing mild nausea, rated 2/10, and moderate fatigue.”
2. Interventions Provided: Detail any medications or treatments administered during the visit, including dosages, routes, and times.
   • Example: “Administered 5 mg morphine sublingually for pain, 1 mg lorazepam for anxiety.”
3. Patient Response: Record the patient's response to interventions, noting any improvements or adverse effects.
   • Example: “Pain reduced to 3/10 within 30 minutes post-medication. No adverse reactions noted.”
4. Plan for Ongoing Management: Outline any changes to the care plan based on the assessment, including new medications, therapies, or referrals.
   • Example: “Increased frequency of pain medication to every 4 hours PRN. Scheduled physical therapy consult for mobility support.”

Patient and Family Interactions

Interactions with the patient and their family are vital components of hospice care, providing emotional support and ensuring their needs and concerns are addressed. Documentation of these interactions should include:

1. Patient's Emotional State: Note observations about the patient's mood, anxiety levels, and overall emotional well-being.
   • Example: “Patient appears calm but expresses concern about increasing fatigue.”
2. Family Dynamics and Support: Record interactions with family members, noting their involvement in care, concerns, and any emotional or educational support provided.
   • Example: “Family expressed concerns about managing pain at night. Provided education on PRN medication use and comfort measures.”
3. Education and Guidance Provided: Provide detailed information or guidance to the patient and family regarding care, symptom management, and what to expect as the illness progresses.
   • Example: “Discussed signs of worsening symptoms and when to call for additional support. Provided literature on managing nausea and dietary recommendations.”
4. Patient and Family Preferences: Document any specific wishes or preferences expressed by the patient or family regarding care, including end-of-life decisions.
   • Example: “Patient reiterated a preference for minimal intervention and comfort-focused care. Family supports this approach.”

PRN (As Needed) Visits

In hospice care, PRN (as needed) visits are crucial in managing unexpected changes in patient conditions. These visits address urgent needs, alleviate distressing symptoms, and provide immediate support to patients and their families. Proper documentation of PRN visits is essential to ensure continuity of care, demonstrate the responsiveness of hospice services, and support the ongoing assessment of the patient's condition.

When to Document PRN Visits

Triggering Symptoms or Events

PRN visits are typically prompted by specific symptoms or events that indicate a change in the patient's condition. Documenting the exact reason for the visit is essential, as it helps to understand the patient's current needs and plan future care. Common triggers for PRN visits include:

1. Uncontrolled Pain: Sudden or escalating pain not relieved by the patient's current pain management regimen.
   • Example: “Patient reported severe, unrelieved pain in the lower back, rated 8/10 despite regular morphine use.”
2. Respiratory Distress: Symptoms such as shortness of breath, increased coughing, or changes in respiratory patterns.
   • Example: “Patient experiencing acute dyspnea, struggling to breathe even while at rest.”
3. Nausea and Vomiting: Persistent nausea or vomiting interferes with the patient's ability to eat, drink, or take medications.
   • Example: “Patient has been vomiting frequently over the past 24 hours, unable to keep fluids down.”
4. Agitation or Anxiety: Sudden or severe agitation, restlessness, or anxiety that impacts the patient's comfort and quality of life.
   • Example: “Patient is very agitated and restless, expressing feelings of intense anxiety and fear.”
5. Changes in Consciousness: Notable changes in the patient's level of consciousness, such as increased drowsiness, confusion, or unresponsiveness.
   • Example: “Patient is significantly more drowsy and less responsive than usual, not waking up fully.”
6. Family Distress Is when the family struggles to manage the patient's symptoms or emotional distress and requires additional support.
   • Example: “Family called expressing concern over managing patient's symptoms and emotional distress at home.”

Interventions Provided and Outcomes

Once the reason for the PRN visit is documented, the next step is to detail the interventions provided and the outcomes observed. This ensures that all care actions are recorded and their effectiveness is evaluated.

1. Administered Medications: Document any medications given during the visit, including the type, dosage, route, and administration time.
   • Example: “Administered 10 mg of morphine buccally for pain management.”
2. Non-Pharmacological Interventions: Record any non-medication interventions used to alleviate symptoms, such as repositioning, breathing techniques, or using comfort items.
   • Example: “Positioned patient upright and provided cool compress to the forehead for comfort.”
3. Monitoring and Assessment: Detail any monitoring or assessments performed to evaluate the patient's condition and response to interventions.
   • Example: “Monitored patient's oxygen saturation levels, which improved from 87% to 93% with the patient going from labored to unlabored breathing after intervention.”
4. Patient Response: Note the patient's response to the interventions, including any improvements in symptoms or adverse reactions.
   • Example: “Patient's pain reduced to 3/10 within 20 minutes of receiving morphine, appeared more relaxed and comfortable.”
5. Family Involvement: Document any interactions with the family, including education provided, emotional support offered, and their involvement in the patient's care.
   • Example: “Educated family on administering breakthrough pain medications and signs to monitor. Provided emotional support and reassured them of the care plan.”
6. Follow-Up Plan: Outline any changes to the care plan or additional follow-up actions needed based on the visit's findings and interventions.
   • Example: “Increased frequency of pain medication to every 3 hours PRN. Scheduled follow-up visit for the next day to reassess pain management.”

Triage Calls

Triage calls are essential to hospice care, providing immediate support and guidance to patients and their families during times of crisis or uncertainty. These calls often occur outside of scheduled visits and can be a lifeline for managing symptoms, addressing concerns, and preventing unnecessary hospitalizations. Proper documentation of triage calls ensures that all aspects of patient care are recorded, facilitating continuity and improving outcomes.

Importance of Documenting Triage Calls

Documenting triage calls is crucial for several reasons. It provides a detailed account of the patient's condition and the interventions made during the call, supporting continuity of care and ensuring that all team members are informed. Additionally, it demonstrates responsiveness and thoroughness, which is important for regulatory compliance and quality assurance.

Critical reasons for documenting triage calls include:

1. Continuity of Care: Detailed records of triage calls ensure that all healthcare providers involved in the patient's care are aware of any changes in condition, interventions provided, and follow-up actions needed.
   • Example: “Documenting that a patient experienced increased pain overnight and received advice for additional pain relief helps the primary nurse to follow up appropriately during the next visit.”
2. Legal and Regulatory Compliance: Accurate documentation is necessary to meet regulatory requirements and to protect against potential legal issues by providing a clear record of the care provided.
   • Example: “A documented record of a triage call discussing new symptoms can demonstrate that the hospice team responded promptly and appropriately to patient needs.”
3. Quality Assurance: Documentation helps evaluate the quality of care provided, identify areas for improvement, and ensure that patient care standards are consistently met.
   • Example: “Reviewing documented triage calls can highlight common issues or areas where additional training might be needed for the hospice team.”
4. Communication with Families: It also provides a reference for any instructions or advice given to the patient or family, ensuring clarity and consistency in communication.
   • Example: “Recording the advice given during a triage call ensures that the family can refer back to it if needed and that the same guidance is reinforced during follow-up visits.”

Date, Time, and Nature of the Call

When documenting a triage call, start with the basics: the call's date, time, and nature. This information sets the context and is critical for tracking the sequence of events.

1. Date and Time: Record the exact date and time of the call. This helps create a timeline for the patient's condition and interventions.
   • Example: “May 15, 2024, 10:30 PM.”
2. Nature of the Call: Provide a brief yet detailed description of why the call was made. This includes the primary concerns or symptoms reported by the patient or caregiver.
   • Example: “The patient's caregiver called to report that the patient is experiencing severe abdominal pain and has been vomiting for the past two hours.”

Actions Taken and Follow-Up Needed

After documenting the nature of the call, detail the actions taken during the call and any follow-up needed. This ensures that all steps are recorded and provides a clear plan for future care.

1. Actions Taken: Document all advice given, interventions recommended, and any immediate steps taken during the call. Be specific about the guidance provided and any medications or treatments advised.
   • Example: “Advised caregiver to administer 5 mg of ondansetron for nausea and to increase the frequency of oral morphine for pain management from every 4 hours to every 2 hours as needed. Elevating the head of the bed is recommended to help with discomfort.”
2. Assessment and Monitoring: Include instructions for monitoring the patient's condition and signs that would necessitate further action or a follow-up call.
   • Example: “Instructed caregiver to monitor for signs of dehydration and to call back if the vomiting persists or if the pain does not subside within an hour.”
3. Follow-Up Needed: Outline any necessary follow-up actions, such as scheduling a visit, further assessments, or additional calls to check the patient's condition.
   • Example: “Scheduled a follow-up visit the next morning to reassess the patient's condition and adjust the care plan as needed. Notified the on-call nurse to check in with the caregiver in two hours.”

Admission

The admission process is critical in hospice care, setting the foundation for the patient's care journey. Comprehensive admission documentation ensures that all aspects of the patient's condition and needs are understood and addressed from the very beginning. This documentation helps develop an effective care plan and supports ongoing eligibility for hospice services. Below, we delve into the critical components of comprehensive admission documentation, highlighting essential practices and the importance of addressing specific areas.

Always Answer the Questions of Why Hospice, Why Now?

When admitting a patient to hospice, it's essential to document the reasons for choosing hospice care at this particular time. This involves explaining the patient's condition and the factors that led to the decision.

• Why Hospice?: Explain why hospice care is the appropriate choice for the patient. This might include the progression of a terminal illness, the patient's declining condition, and the goal of focusing on comfort rather than curative treatments.
  • Example: “Patient has advanced-stage lung cancer with metastasis to the brain, experiencing significant pain and shortness of breath. Curative treatments are no longer effective, and the focus is now on palliative care to ensure comfort and quality of life.”
• Why Now?: Detail the immediate circumstances that prompted the hospice referral. This often includes recent changes in the patient's condition or symptoms that have become unmanageable.
  • Example: “Recent increase in pain and respiratory distress, coupled with weight loss and decreased functional ability, has led to the decision for hospice care to manage symptoms and provide support.”

Initial Patient Assessment

A thorough initial assessment, which includes several key elements, is crucial for understanding the patient's current status and needs. It forms the basis for the hospice care plan.

• Physical Assessment: Document the patient's vital signs, physical condition, and notable symptoms or issues. This should cover all respiratory, cardiovascular, gastrointestinal, musculoskeletal, and neurological systems.
  • Example: “Vital signs: BP 110/70, HR 88 bpm, RR 22 breaths/min, Temp 98.4°F. Patient reports severe pain in the lower back, rated 8/10, and significant shortness of breath upon exertion.”
• Psychosocial Assessment: Assess the patient's emotional and psychological state, including mood, anxiety, and mental health concerns. Also, the patient's support system and family dynamics should be considered.
  • Example: “Patient expresses feelings of anxiety about their condition and concern for their family's well-being. Family is supportive but overwhelmed, particularly the primary caregiver.”

Baseline Measurements and Patient History

Documenting baseline measurements and a comprehensive patient history provides a clear starting point for tracking changes. This includes:

• Baseline Measurements: Record initial measurements such as weight, height, body mass index (BMI), and any laboratory values available.
  • Example: “Weight: 150 lbs, Height: 5'6”, BMI: 24.2. Recent lab values show elevated liver enzymes and decreased hemoglobin levels.”
• Patient History: Detail the patient's medical history, including previous diagnoses, treatments, surgeries, and any relevant family medical history.
  • Example: “History of COPD, hypertension, and diabetes. Underwent chemotherapy and radiation for lung cancer, with recent progression to metastatic disease.”

Consider Documenting the SBAR

The SBAR (Situation, Background, Assessment, Recommendation) framework is structured for documenting and communicating critical information. Applying SBAR to hospice admissions ensures clarity and thoroughness.

• Situation: Describe the current situation that necessitates hospice admission.
  • Example: “Patient with advanced lung cancer experiencing uncontrolled pain and shortness of breath, seeking palliative care.”
• Background: Provide relevant background information, including medical history and recent changes in condition.
  • Example: “Diagnosed with lung cancer three years ago, recently developed metastases to the brain, with significant functional decline over the past month.”
• Assessment: Conduct and document a comprehensive nursing assessment, noting the patient's physical and emotional state.
  • Example: “Assessment reveals severe pain (8/10), increased respiratory distress, anxiety, and significant weight loss (10 lbs in the past month).”
• Recommendation: Make a clear recommendation regarding the patient's hospice admission, including the primary terminal diagnosis and any supporting diagnoses.
  • Example: “Recommend admission to hospice under the primary diagnosis of metastatic lung cancer, with secondary diagnoses of COPD and diabetes. Focus on symptom management and palliative care.”

Document Local Coverage Determination (LCD) Areas the Patient Meets for Hospice Eligibility

Local Coverage Determination (LCD) guidelines help ensure that patients meet the criteria for hospice eligibility. Thorough documentation of these criteria supports the justification for hospice care and compliance with regulatory requirements.

• Meeting LCD Criteria: Document specific symptoms, conditions, and measurable data that align with LCD guidelines for hospice eligibility.
  • Example: “Patient meets LCD criteria for hospice eligibility based on a primary diagnosis of metastatic lung cancer with evidence of significant weight loss, increased pain, and declining functional status.”
• Supporting Documentation: Include detailed clinical evidence and observations that support the patient's eligibility under the LCD.
  • Example: “Supporting documentation includes recent imaging showing disease progression, physician notes on functional decline, and nursing assessments of increased symptom burden.”

Recertification

Recertification is a critical process in hospice care, ensuring that patients continue to meet eligibility criteria and receive necessary services. This process involves thorough documentation and assessment to demonstrate that the patient qualifies for hospice care based on continued decline and specific medical criteria. Proper recertification complies with regulatory requirements and ensures appropriate and compassionate care.

Documentation of Continued Decline

One of the primary goals of recertification is to document the patient's ongoing decline. This documentation should be comprehensive and detailed, capturing all aspects of the patient's condition and any changes since the last certification period. Key areas to focus on include:

1. Physical Decline: Record observable signs of physical decline, such as weight loss, decreased mobility, and worsening symptoms.
   • Example: “The Patient has lost 5 pounds in the last month and now weighs 130 pounds. Mobility has decreased significantly, and the patient now requires assistance with all ADLs.”
2. Functional Decline: Document changes in the patient's ability to perform Activities of Daily Living (ADLs), such as bathing, dressing, eating, and ambulating.
   • Example: “Patient is now bedbound and requires assistance with feeding and personal hygiene. Previously able to transfer with assistance, now completely dependent.”
3. Cognitive Decline: Note any changes in cognitive function, such as increased confusion, memory loss, or decreased communication ability.
   • Example: “Patient exhibits increased confusion and disorientation, often unable to recognize family members. Communication is limited to non-verbal cues.”
4. Symptom Burden: Describe the progression of symptoms and their impact on the patient's quality of life, including pain, dyspnea, fatigue, and other distressing symptoms.
   • Example: “Pain levels have increased, with patient reporting pain of 7/10 despite medication adjustments. Shortness of breath has worsened, requiring frequent use of oxygen.”
5. Medical Interventions and Responses: Include details about any medical interventions provided, their effectiveness, and the patient's response to treatment.
   • Example: “Increased dosage of pain medication to manage escalating pain, but the patient continues to report significant discomfort. Frequent adjustments to oxygen levels to manage dyspnea, with limited relief.”

Supporting Evidence for Recertification

To ensure that recertification is justified, providing supporting evidence demonstrating the patient's ongoing decline and need for hospice care is crucial. This evidence should be specific and measurable, aligning with the criteria set forth by regulatory bodies.

1. Clinical Documentation: Include detailed clinical notes from assessments and visits highlighting the patient's decline.
   • Example: “Clinical notes from the last three visits indicate progressive weight loss, increased dependency on caregivers, and declining cognitive function.”
2. Physician's Narrative: Provide a narrative from the attending physician or hospice medical director that summarizes the patient's condition and supports the need for continued hospice care.
   • Example: “Dr. Smith's narrative states that the patient's metastatic cancer continues to progress, with significant physical and functional decline noted over the past 90 days.”
3. Objective Measurements: Use objective measurements, such as weight, vital signs, and lab results, to provide concrete evidence of decline.
   • Example: “Patient's weight has decreased from 135 lbs to 130 lbs over the last month. Lab results show declining kidney function, with increased creatinine levels.”
4. Interdisciplinary Team (IDT) Notes: Incorporate notes from the interdisciplinary team, including nurses, social workers, and chaplains, to provide a holistic view of the patient's condition and needs.
   • Example: “IDT notes indicate increased anxiety and depression, with social worker reporting patient's withdrawal from family interactions and chaplain noting spiritual distress.”
5. Symptom Scales and Tools: Utilize symptom scales and assessment tools to quantify the patient's symptom burden and functional status.
   • Example: “Using the Palliative Performance Scale (PPS), the patient's score has decreased from 50% to 30% over the last two months, indicating a significant decline.”
6. Local Coverage Determination (LCD) Criteria: Ensure documentation aligns with the Local Coverage Determination (LCD) criteria for hospice eligibility, clearly stating which criteria the patient meets.
   • Example: “Patient meets LCD criteria for hospice eligibility due to a primary diagnosis of advanced dementia with associated weight loss, functional decline, and severe cognitive impairment.”

Death

The death of a hospice patient is a profound moment that marks the end of their journey and the culmination of the care provided by the hospice team. Proper documentation of this event is essential for medical and legal reasons, as well as to honor the patient and support their family during this challenging time. Thorough and compassionate documentation ensures that all aspects of the patient's final moments are recorded accurately, providing a complete picture of their end-of-life care.

Date, Time, and Circumstances of Death

Documenting death's date, time, and circumstances is crucial for maintaining accurate records and ensuring that all legal and regulatory requirements are met.

1. Date and Time: Record the exact date and time of death as accurately as possible. This information is vital for legal documentation and the family's records.
   • Example: “Patient was pronounced deceased on June 1, 2024, at 3:45 AM.”
2. Circumstances of Death: Describe the circumstances surrounding the patient's death, including where it occurred, who was present, and any notable events or changes leading up to the moment of death.
   • Example: “Patient passed away peacefully at home, in their bed, with family members present. In the hours leading up to death, the patient exhibited decreased respiratory effort and increased periods of apnea. Comfort measures were maintained throughout.”

Family Interactions and Final Care Provided

The interactions with the patient's family and the care provided in the final moments are integral to the hospice experience. Documenting these details helps provide a complete picture of the care given and supports the family's needs during their grief.

1. Family Presence and Interactions: Record which family members were present at the time of death and describe any interactions or conversations. This helps capture the emotional and supportive aspects of hospice care.
   • Example: “Patient's spouse and two children were at the bedside. Family members expressed their love and said their goodbyes, holding the patient's hands and offering comfort. The hospice nurse provided emotional support and facilitated a calm environment.”
2. Final Care Provided: Detail the care measures taken to ensure the patient's comfort and dignity in their last moments. This includes any medications administered, positioning, and other comfort measures.
   • Example: “Administered 2 mg of morphine sublingually for pain management at 2:30 AM. Positioned the patient on their side to facilitate easier breathing. Ensured the patient was covered with a warm blanket and kept the room quiet and peaceful.”
3. Post-Mortem Care: Document the steps taken for post-mortem care, including care of the body, notifications made, and support provided to the family.
   • Example: “After pronouncing the patient deceased, the body was cleaned and positioned with respect. Notified the attending physician and the funeral home per the family's request. Provided the family with information on next steps and bereavement support services.”
4. Bereavement Support: Record any immediate bereavement support offered to the family and plans for follow-up support.
   • Example: “Offered immediate emotional support to the family and provided contact information for the hospice's bereavement counselor. Scheduled a follow-up call the next day to check in on the family and offer additional support.”

Discharges

Discharges from hospice care can occur for various reasons, including failure to decline, revocation by the patient or family, discharge for cause, relocation out of the service area, and transfer to another hospice provider. Each type of discharge requires thorough and precise documentation to ensure continuity of care and compliance with regulatory standards.

Discharge for Failure to Decline

Criteria for Discharge

Patients may be discharged from hospice care if they no longer meet the eligibility criteria, often due to stabilization or improvement in their condition. The key criteria for discharge include:

• Stabilization: The patient's condition has stabilized without significant decline over multiple certification periods.
• Improvement: The patient shows marked improvement in their health status, which suggests they no longer have a life expectancy of six months or less if the disease follows its normal course.

Documentation of Stabilization or Improvement

When discharging a patient for failure to decline, it's essential to document the following:

1. Clinical Assessments: Detailed notes from regular assessments indicating the patient's stabilized or improved condition.
   • Example: “Patient has shown no significant decline over the past three months, with consistent vital signs and stable weight. Mobility has improved, and no new or worsening symptoms.”
2. Medical Interventions and Responses: Document any medical interventions and the patient's positive responses to these treatments.
   • Example: “Patient responded well to new pain management regimen, reporting consistent pain levels of 3/10, down from 7/10.”
3. IDT Review: Notes from interdisciplinary team meetings discussing the patient's condition and the decision to discharge.
   • Example: “IDT meeting on May 15, 2024, concluded that the patient no longer meets hospice eligibility criteria due to sustained improvement in functional status and symptom management.”

Discharge Due to Revocation

Patient or Family Decision to Revoke Hospice Care

Patients or their families may choose to revoke hospice care at any time. This decision can be driven by various factors, including a desire to pursue curative treatments or dissatisfaction with hospice services.

Documentation of Discussions and Reasons for Revocation

1. Patient/Family Discussions: Thoroughly document conversations with the patient and family regarding their decision to revoke hospice care.
   • Example: “On June 1, 2024, the patient's daughter expressed a desire to pursue aggressive treatment options for the patient's cancer. Discussed potential outcomes and ensured understanding of hospice revocation implications.”
2. Reasons for Revocation: Clearly state the reasons provided by the patient or family for revoking hospice care.
   • Example: “Patient and family decided to revoke hospice care to explore new chemotherapy options recently recommended by their oncologist.”
3. Formal Documentation: Ensure all required forms and documents for revocation are completed and signed.
   • Example: “Revocation form signed by the patient's legal representative on June 1, 2024, and submitted to hospice administration.”

Discharge for Cause

Criteria and Circumstances for Discharge for Cause

Discharge for cause occurs when the patient or family's behavior makes delivering safe and appropriate care impossible. Criteria include:

• Non-compliance: Patient repeatedly refuses care or medications.
• Safety Concerns: Behavior that threatens the safety of the patient, family, or hospice staff.

Documentation of Issues and Interventions

1. Behavioral Documentation: Record specific instances of non-compliance or unsafe behavior.
   • Example: “On multiple occasions, the patient refused medication administration and home visits, making it impossible to provide adequate care.”
2. Interventions and Outcomes: Detail the interventions attempted to address these issues and their outcomes.
   • Example: “Held family meetings on May 15 and May 22, 2024, to address non-compliance issues. Despite multiple interventions, the patient continued to refuse care.”
3. IDT and Administrative Notes: Document the interdisciplinary team's discussions and the final decision to discharge for cause.
   • Example: “After thorough review, IDT and hospice administration agreed to discharge the patient for cause on June 1, 2024, due to ongoing non-compliance and safety concerns.”

Discharge for Moving Out of Service Area

Documentation of Patient Relocation

When a patient moves out of the hospice service area, detailed documentation of the relocation is required.

1. Patient's New Address: Record the new address and contact information for the patient.
   • Example: “Patient relocated to 123 New Town Road, Springfield, effective June 1, 2024.”
2. Reason for Move: Document the move and any discussions with the patient or family about the relocation.
   • Example: “Patient moved closer to extended family for additional support.”

Coordination of Care and Transfer Details

1. Coordination Efforts: Detail the steps to coordinate care with a new hospice provider or healthcare services in the new location.
   • Example: “Coordinated transfer of care with Springfield Hospice. The writer sent all medical records and discussed the patient's care plan with the receiving hospice team.”
2. Transfer Documentation: Complete and document all necessary transfer forms and communications.
   • Example: “Completed and sent transfer documentation to Springfield Hospice on May 30, 2024. Confirmed receipt and acceptance of patient with the new provider.”

Transfer to Another Hospice Provider

Documentation of Transfer Reasons

Transfers to another hospice provider may occur for various reasons, such as patient choice or a better fit with another provider's services.

1. Reason for Transfer: Document the specific reason for the transfer.
   • Example: “Patient's family requested transfer to another hospice provider closer to their home for convenience.”
2. Patient/Family Request: Record any formal requests made by the patient or family.
   • Example: “Formal transfer request submitted by patient's daughter on May 25, 2024.”

Coordination with the Receiving Hospice Provider

1. Communication with New Provider: Detail the communication and coordination efforts with the receiving hospice provider to ensure a smooth transition.
   • Example: “Contacted receiving hospice provider on May 26, 2024. A full summary of the patient's current condition, care plan, and needs.”
2. Transfer of Medical Records: Ensure all medical records and relevant documentation are sent to the new provider.
   • Example: “Sent complete medical records, including recent assessments and medication list, to the new provider on May 27, 2024.”
3. Follow-Up: Note any follow-up actions taken to confirm the successful transfer of care.
   • Example: “The writer followed up with the receiving provider on June 2, 2024, to confirm that the patient was admitted and that the care transition was smooth.”

Importance of Negative-Based Wording

Effective and accurate documentation is crucial in hospice care, particularly when describing a patient's decline. Using negative-based wording can significantly enhance the clarity and precision of your documentation, ensuring that it accurately reflects the patient's condition and supports ongoing hospice eligibility.

Clarity in Documenting Patient Decline

Negative-based wording focuses on what a patient cannot do or their symptoms rather than their abilities or positive aspects of their condition. This approach is critical in hospice care for several reasons:

1. Highlighting Decline: Hospice eligibility is based on a patient's decline and the progression of their terminal illness. Negative-based wording directly illustrates this decline, making it clear that the patient's condition worsens.
   • Positive Example: “Patient is unable to walk without assistance.”
   • Negative Example: “Patient walks with assistance.”
2. Regulatory Compliance: Medicare and other regulatory bodies require clear evidence of a patient's decline to justify hospice care. Negative-based wording straightforwardly provides this evidence.
   • Positive Example: “Patient requires frequent repositioning due to inability to move independently.”
   • Negative Example: “Patient is repositioned frequently.”
3. Consistency and Precision: Negative-based wording reduces ambiguity in documentation. It ensures that all caregivers and healthcare providers understand the severity of the patient's condition.
   • Positive Example: “Patient is disoriented and confused.”
   • Negative Example: “Patient is oriented.”

Examples of Effective Negative-Based Wording

Using negative-based wording can be simple and effective. Here are some examples that illustrate how to frame observations and assessments in a way that highlights decline and incapacity:

Disoriented vs. Oriented

• Positive Wording: “Patient is oriented to person but not to place or time.”
• Negative Wording: “Patient is disoriented to place and time but knows own identity.”

Nutritional Intake

• Positive Wording: “Patient consumed 75% of their meal.”
• Negative Wording: “Patient cannot consume more than 75% of their meal.”

Ambulation

• Positive Wording: “Patient ambulates with a rolling walker.”
• Negative Wording: “Patient unable to ambulate without using a rolling walker.”

These examples demonstrate the power of negative-based wording to convey a patient's limitations and decline more accurately. This approach ensures that documentation provides an unambiguous picture of the patient's condition, essential for care planning and eligibility assessments.

Conclusion

Thorough and accurate documentation is the cornerstone of effective hospice care. As hospice nurses, your meticulous attention to detail in documenting patient conditions, care interventions, and interactions with families is critical in ensuring the quality of care provided to patients during their end-of-life journey.

Summary of Key Points

1. Understanding the Hospice Nursing Narrative: The hospice nursing narrative is a detailed account of a patient's condition and care. Ensuring continuity of care is crucial, as well as supporting eligibility for hospice services and providing a comprehensive record of the patient's end-of-life journey.
2. Length of the Hospice Nursing Narrative: The length of the narrative should be dictated by the complexity of the patient's condition and the nature of the visit. While documentation should be concise, it must also be comprehensive enough to capture all relevant details, ensuring that nothing significant is omitted.
3. Key Documentation Areas to Support Continued Hospice Eligibility: Essential areas include clinical documentation of symptoms and signs of decline, medical interventions and outcomes, functional decline in ADLs and cognitive status, and nutritional intake assessments. This documentation is vital for justifying continued hospice care.
4. Routine Visits: Documentation should include regular assessments, symptom management, and interactions with the patient and family during routine visits. This ensures a continuous understanding of the patient's condition and care needs.
5. PRN (As Needed) Visits: Document PRN visits based on specific triggering symptoms or events, the interventions provided, and their outcomes. This helps in understanding acute changes in the patient's condition and the effectiveness of interventions.
6. Triage Calls: Documenting triage calls is essential for maintaining a comprehensive patient care record. Include the call's date, time, nature, actions taken, and any necessary follow-up.
7. Admissions: Comprehensive admission documentation should address why hospice care is needed now, initial assessments, baseline measurements, patient history, and alignment with local coverage determination (LCD) criteria for eligibility.
8. Recertification: Recertification requires detailed documentation of the patient's continued decline, including clinical notes, physician's narratives, objective measurements, and interdisciplinary team (IDT) notes. This supports the justification for continued hospice care.
9. Death: Thorough documentation at the time of death should include the date, time, and circumstances, as well as family interactions and final care provided. This ensures a respectful and complete record of the patient's last moments.
10. Discharges: Documentation for various discharges (failure to decline, revocation, discharge for cause, moving out of service area, transfer to another provider) should include reasons, discussions with the patient/family, and coordination efforts. This ensures that the patient's transition is smooth and well-documented.
11. Importance of Negative-Based Wording: Negative-based wording enhances clarity in documentation by focusing on the patient's limitations and decline. This approach is critical for demonstrating hospice eligibility and supporting regulatory compliance.

Importance of Detailed and Accurate Documentation for Patient Care and Compliance

Patient Care

Accurate and detailed documentation ensures that every aspect of the patient's condition and care plan is communicated among the healthcare team. This consistency is vital for:

• Continuity of Care: Detailed records enable all caregivers to understand the patient's history, current status, and care plan, ensuring seamless transitions and coordinated care.
• Quality of Care: Thorough documentation helps identify trends and changes in the patient's condition, facilitating timely and appropriate interventions that enhance the patient's comfort and quality of life.

Compliance

In hospice care, regulatory compliance is paramount. Detailed and accurate documentation supports compliance with Medicare and other regulatory bodies by:

• Justifying Hospice Eligibility: Clear records of patient decline and care interventions are essential for demonstrating that patients meet eligibility criteria for hospice care.
• Audits and Reviews: Comprehensive documentation provides the necessary evidence for audits and reviews, protecting the hospice organization from potential penalties or reimbursement issues.

Resources

The length of the Hospice Narrative Note (Facebook Video by Shelley Blewett Henry, RN, CHNP)

The Amity Group Documentation Guides (the writer has no affiliation with The Amity Group or Shelley Blewett Henry, RN, CHNP, other than the appreciation of her heart and the goals of this group to support hospice nurses).

National Hospice and Palliative Care Organization

Centers for Medicare & Medicaid Services (CMS) Hospice Guidelines

Hospice Fundamentals

Hospice Documentation: Painting the Picture of the Terminal Patient

Documentation to Support Patient Decline

How To Avoid Hospice Survey Deficiencies

How to Survive a Hospice Survey: 5 Tips

Hospice Educational Resources

Free and paid CEU Courses related to Hospice

The Importance of Hospice Documentation within the Visit