As hospice nurses, our primary focus is comfort at the end of life. We work tirelessly to ensure our patients receive the best care during their end-of-life journey. An aspect of that care that is often overlooked but critical is timely documentation.

Documenting hospice visits at the bedside is crucial for several reasons. Not only does it help ensure that our patients receive the best possible care, but it also helps the hospice team and reduces issues when the caregiver must be involved in triage services. Here are just a few reasons why documenting hospice visits at the bedside is so essential:

It helps the patient

Documenting hospice visits at the bedside helps the patient primarily. By documenting our assessments and interventions, we ensure patients receive the necessary care. It also helps us keep track of any changes in the patient’s condition and adjust their care plan accordingly.

It helps the hospice team

Documenting hospice visits at the bedside also helps the entire hospice team. Keeping detailed and accurate records allows us to share information with other team members, such as physicians or social workers. This can be especially helpful if the patient’s care plan needs to be adjusted or if there are any sudden changes in their condition.

It reduces issues when involving triage services

Finally, documenting hospice visits at the bedside can help reduce issues involving triage services. If a patient’s caregiver needs to call the hospice triage line, having detailed documentation can help the triage nurse quickly assess the situation and make informed decisions about the patient’s care. It also ensures a clear record of what has been done for the patient so far, which can be helpful for any questions or concerns.

Attitude about Documenting in Front of the Patient

One of the most significant barriers to documenting at the bedside is the discomfort some nurses feel about documenting in front of the patient. Nurses may feel that it’s intrusive or disrupts the conversation with the patient.

However, documenting at the bedside is crucial for ensuring timely and accurate documentation, which is essential for providing quality care. Here are a few tips to overcome this barrier:

• Develop one or more templates you can follow so the layout of your narrative is consistent and, therefore, quicker to type and follow. For example, for routine visits, I start with age, gender, and reason for service; then, incoming coordination reports (i.e., spouse or 3rd party caregiver reported ______ since last visit), list specific declines you want to call out for others to see or to make it easier to find in the note for when recertification comes along. The actual physical assessment, then phone calls noting who was called about what, including any orders/references that another party may need to follow up, followed by teaching to the family closing with narcotic counts.
• To minimize the time spent documenting, pre-document areas that do not require physical assessment in your vehicle before entering the home.
• Explain to the patient why you are documenting during the visit and assure them that it is part of the care process.
• Position yourself in a non-intrusive way to maintain eye contact with the patient.
• Using a laptop or tablet to document can be less intrusive than traditional pen and paper.

Finally, if you are like me and believe the best way to demonstrate compassion is with minimal technological interference and yet understand the critical value of timely documentation done on-site, may I suggest a napkin approach that one might use to pick up something nasty on the floor? I.e., you take a napkin, wrap the item in the napkin, and throw it away… here’s how that looks with on-site documentation:

1. Your entrance to and with the patient and family. There’s just you, and you put aside your nursing bag and any technology. You embrace (and this can be visual, a handshake, or a hug, depending on body language, et al.) the patient and family and soak things in. If this is your first time with the patient and family, explain how much you love your job and how you want to keep technology and mechanical equipment to a minimum. And go over how each visit will involve a hello, how you are doing, how you have been, etc. Then, a physical assessment, the documentation before closing remarks, and follow-up free of technology and mechanics.
2. Have your opening discussions taking notes, for which I recommend using a clipboard.
3. Do your physical assessment, take careful notes, and consider a clipboard.
4. Then, sit nearby and chart the visit on your tablet/laptop, doing your best to have frequent eye contact with the patient and family. As you get close to the point of the documentation where you would make phone calls, explain you are now going to call in new orders, refills, etc., and let the patient and family hear your calls and conversations as it does reassure them and build trust with them that you are thorough and meeting their needs. Document those calls, including who you talked to and expected outcomes, such as delivery tomorrow or an order ID, along with any follow-up needed.
5. Document the education you will provide shortly and use the education discussion to separate you from the technology.

Tips for documenting hospice visits at the bedside

Now that we’ve established why documenting hospice visits at the bedside is so essential, let’s talk about some tips for doing it effectively.

• Document during the visit: One of the most important things you can do is document during the visit. This ensures that all your assessments and interventions are fresh in your mind and that you don’t forget anything important.
• Be thorough and detailed: When documenting, it’s essential to be as comprehensive and detailed as possible. Please include all relevant information, such as any symptoms they are experiencing and any interventions you have performed. Ensure you are documenting declines that will be noted or help with recertification.
• Use clear and concise language: It’s also important to use clear and concise language when documenting. Avoid using medical jargon or abbreviations that may be difficult for others to understand.
• Record all telephone calls made, the reason for the call, to whom you spoke, any order or reference ID numbers, and details that may help another person to follow up on the results of the call(s).
• Finally, before leaving the patient’s room, ensure that everything is accurate and complete and that you have documented everything you need to.

Conclusion

In conclusion, documenting hospice visits at the bedside is a crucial aspect of hospice care. By keeping detailed and accurate records, we can provide the best possible care for our patients, help the hospice team, and reduce issues involving triage services. By following these tips for effective documentation, we can ensure that our patients receive the best possible care during their end-of-life journey.

Resources

NHPCO Palliative Care Playbook for Hospices Documentation: This resource discusses the multiple functions of documentation, including communication, care records, reimbursement, quality assurance, and process improvement. It emphasizes that effective documentation can improve the quality of care and patient safety.

Hospice Documentation What You Need to Know – Hospice Nurse Hero: This article outlines the fundamentals of hospice documentation and emphasizes the importance of documenting at the bedside to ensure accuracy and provide the team with the information they need to care for the patient.

What you will learn – Hospice Fundamentals: This resource highlights the importance of good documentation in establishing and supporting eligibility for the Medicare Hospice Benefit, determining proper reimbursement, and supporting compliance with the Medicare CoPs, state licensure regulations, and accreditation standards.