01 / ADAPTABLE OUTLINE
What to document
Goals & interval course
Reason for the visit, established hospice context, patient and caregiver priorities, changes since the last assessment, information source, and communication or capacity limitations.
Symptoms, function & examination
Pain, dyspnea, nausea, anxiety or agitation, bowel function, intake, swallowing, sleep, mobility, skin comfort, and the focused examination actually performed.
Medication response & comfort plan
Verified medicines, formulation and concentration, scheduled and PRN doses used, benefit, adverse effects, route feasibility, and individualized adjustments authorized by the treating team.
Caregiver support & coordination
Education, medication access, equipment, psychosocial or spiritual needs, interdisciplinary communication, after-hours contact, reassessment, and a goal-concordant escalation plan.
02 / WORKED EXAMPLE
Home hospice follow-up for symptom control
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
Interval history & goals
A 78-year-old patient with advanced metastatic cancer is seen for a scheduled home hospice follow-up. The patient states that comfort and remaining at home are current priorities. The caregiver reports less activity and more assistance with personal care this week. The patient and caregiver both contribute to the history.
Symptom review & examination
Pain is reported as 2/10 at rest and acceptable to the patient. No nausea or breathlessness at rest is reported. The caregiver documents a bowel movement yesterday. The patient is awake, responds appropriately, and appears comfortable with unlabored breathing during the visit. No new agitation is observed.
Comfort-focused assessment & plan
Current symptom control is acceptable to the patient. The hospice medication record, scheduled doses, PRN use, response, and adverse effects were reviewed with the nurse; no new medication dose or route was ordered today. Continue the verified individualized comfort plan and bowel regimen. Offer mouth care, positioning for comfort, and assistance with activities according to tolerance and preference.
Care coordination
Reviewed medication access and when to call hospice for uncontrolled symptoms, new swallowing difficulty, or excessive sedation. The caregiver has the hospice's 24-hour contact instructions. Nursing follow-up is planned for tomorrow, with earlier contact for a change. Equipment and caregiver support needs were relayed to the interdisciplinary team. This visit does not independently certify hospice eligibility or alter advance-care orders.
03 / SETTING-SPECIFIC CARE PLAN
Treatment, monitoring & coordination
Adapt the plan to the patient, care setting, and goals. These prompts do not create orders or imply that care was performed.
Individualized symptom treatment
For each symptom, record severity, the patient's comfort goal, current treatment, actual PRN use, effect, and toxicity. Any new opioid or sedating medicine requires review of prior exposure, organ function, interactions, route, concentration, and monitoring; this template supplies no universal starting regimen.
A written, coordinated plan
Align interventions with the individualized hospice plan and involve the patient or representative, caregiver, attending clinician, and interdisciplinary team. Record changes and responsibilities so care remains consistent across visits.
Support and escalation
Document caregiver teaching, supplies, equipment, follow-up timing, and how to obtain urgent symptom support. Goals of care and resuscitation orders must be verified separately; hospice enrollment alone is not a code-status order.
A common documentation question
Should every hospice note describe the patient as actively dying?
No. Document the actual trajectory, symptoms, function, and goals. Hospice care does not imply that every visit is an actively dying assessment; use that description only when clinically supported.