From the Guidelines
A comprehensive hospice admission note should include the patient's demographic information, primary diagnosis warranting hospice care, relevant medical history, current medications, allergies, and advance directives, as well as a thorough assessment of their personal goals, values, and expectations 1. When writing a hospice admission note, it is essential to document the patient's functional status using scales like the Palliative Performance Scale (PPS) or Karnofsky Performance Status, along with a thorough physical examination. The note should detail the patient's symptoms (pain, dyspnea, nausea, anxiety, etc.) and current management plans. A psychosocial assessment covering the patient's emotional state, family dynamics, caregiver availability, and spiritual needs is essential, as it helps to identify goals and expectations that might be better met by the hospice model of palliative care 1. The note must clearly document that the patient or their representative understands and consents to hospice care, including acknowledgment of the terminal prognosis with a life expectancy of six months or less. A comprehensive care plan addressing symptom management, medication regimens (including opioids like morphine, hydromorphone, or fentanyl with specific dosing), and psychosocial support should be outlined, ensuring that the patient's values, goals, and preferences are respected and prioritized 1. The note should also include emergency protocols, DNR status, and the schedule for hospice team visits, as well as a plan for regular assessment of the patient's status and decision-making capacity. By following these guidelines and prioritizing the patient's personal goals, values, and expectations, healthcare providers can ensure that hospice care is tailored to meet the unique needs of each patient, improving their quality of life and reducing morbidity and mortality.
From the Research
Key Components of a Comprehensive Hospice Admission Note
To write a good hospice admission note, several key components should be included:
- Patient and caregiver goals of care, as identified in studies 2, 3, which highlight the importance of assessing patients' and caregivers' needs related to end-of-life psychosocial issues
- A comprehensive assessment of the patient's physical, emotional, and social needs, as outlined in 4, which discusses the use of the Calgary-Cambridge Model for history taking and physical assessment in holistic palliative care
- Medication reconciliation, including herbal medicine and supplement use, as emphasized in 5, which identifies 12 herbal medicines that should be routinely assessed on hospice admission due to their potential for harm or drug interactions
- Documentation of the patient's and caregiver's understanding of hospice care and services, as noted in 6, which highlights the importance of integrating the patient and caregiver perspective to improve the quality of admission conversations
Best Practices for Hospice Admission Notes
Best practices for writing hospice admission notes include:
- Using a standardized assessment tool, such as the Social Work Assessment Tool 2, to guide the assessment of patients' and caregivers' needs
- Documenting patient and caregiver goals of care, as well as the plan of care, to ensure that all team members are aware of the patient's and caregiver's needs and priorities
- Conducting a thorough medication reconciliation, including herbal medicine and supplement use, to prevent potential adverse drug events and drug interactions
- Ensuring that the patient and caregiver have a clear understanding of hospice care and services, and that their expectations and objectives are aligned with those of the hospice team, as discussed in 6