Hospice Routine Visit Template

Published on March 24, 2023

Updated on December 25, 2023

One of the ways that I keep the bedside documentation to typically under 15-minutes (admission visits not included) is by creating muscle memory through the use of consistent templates that I follow based on the type of visit (routine, PRN, recertification, death, and admission).

I've previously shared my recertification template, so for today, let me share my routine visit template. For those that are new, routine visits are scheduled ahead of time and while you may arrive to find a crisis going on before you, the visit itself was scheduled and therefore considered routine. It is considered a part of the four levels of care for hospice according to Medicare guidelines

The template for routine visits is broken down into sections where I use a paragraph for each section:

  • Age Gender “on service for” Primary DX. For example, 92-year-old female on service for Alzheimer.
  • Coordination notes for any status reports received PRIOR to arrival which could be notes from , CNA's, MSW's, etc.
  • Coordination notes from the onsite caregiver, family member, or primary nurse if at a facility. Take careful note that best practice for Medicare involves the parties showing and providing evidence coordination between all parties is taking place; remember the old saying, “If it wasn't documented, it was never done.”
  • At least weekly, a list of declines by line item (each decline on its own line) that have occurred in the last one to no more than two weeks.
  • The actual physical assessment notes where I do my best to use negative language such as disoriented x3 vs. oriented to self only.
  • Telephone calls including the person on the other end, the company/organization, why the call was made, and expected outcome. This can be as simple as writing “telephone call to John Doe at XYZ pharmacy to refill duonebs for Saturday delivery on request of the family” or as detailed as a specific type of x-ray to rule out ________ with reference # or order ID #. Each call is on its own line.
  • Education provided to _____ on the disease process and progression including any specific areas you called out that might involve a PRN visit by another party. For example, I have a patient with a history of seizures where one family member is extremely concerned about the diazepam rectal syringes to deliver the 12.5 mg of diazepam. And therefore, every time I re-educate and reinforce about the medication use, I am extremely specific that it was taught/reviewed. Remember, if it was not documented it was not done, and the last thing you need is to have a family member state they were never told/educated especially if it is something critical.
  • If the visit was done for a facility patient, then document who you updated after the visit as part of post-coordination along with any key areas such as complaints of pain, nausea, vomiting, intractable cough, etc.
  • Narcotic counts for home patients.

In my experience, if you find a template (it doesn't have to be mine above) and use it consistently, you are less likely to miss things and more likely to be encouraged to document within the visit itself.

Learn to touch type, and consistent methods of what you document will lead to reasonable documentation times without burning you out.

Oh hi there 👋 It's nice to meet you.

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