Should medication changes made by a primary care physician (PCP) in consultation with a hospice nurse on behalf of a non-verbal patient be documented in a visit note?

Documentation of Medication Changes in Hospice Care

Yes, medication changes made by a PCP in consultation with a hospice nurse on behalf of a non-verbal patient must be documented in a visit note with specific required elements including date, clinician name, the medication changes made, and communication of these changes to all relevant healthcare providers.

Required Documentation Elements

The medication reconciliation guidelines establish clear documentation requirements that apply to this scenario:

• Document all medication changes in a centralized location with the date and name of the clinician who performed the medication reconciliation 1
• Highlight changes from the prior medication list to ensure visibility of what was modified 1
• Document any unresolved discrepancies with a plan of action if the hospice nurse and PCP disagreed on any aspect 1
• Maintain accurate records of medication problems that prompted the changes 1

Communication Requirements Beyond Documentation

Documentation alone is insufficient—the guidelines mandate active communication:

• Provide the updated medication list to all relevant healthcare providers including the hospice team, pharmacy, and any other physicians involved in care 1
• Update the list regularly as more information becomes available and communicate with each change to maintain "one source of truth" 1
• Enable tracking of progress on any medication-related action plans through patient care conferences 1

Studies demonstrate that nearly 90% of family physicians and community pharmacists who received updated medication reconciliation forms were satisfied and felt it improved quality of care 1.

Special Considerations for Non-Verbal Hospice Patients

For non-verbal patients in hospice care, additional documentation considerations apply:

• Document the rationale for medication changes in the context of goals of care, as deprescribing and medication adjustments are common in end-of-life care 1
• Record consultation with the hospice nurse as part of the multidisciplinary team (MDT) process, which is essential for synchronized decision-making in palliative care 1
• Document who has decision-making authority for the non-verbal patient, as this affects the consent and communication process 1

Legal and Quality Metric Implications

Proper documentation serves multiple critical functions:

• Meets quality metrics for medication reconciliation, which are increasingly monitored in healthcare settings 1
• Provides legal protection by creating a clear record of clinical decision-making and the consultation process 1
• Facilitates continuity of care across transitions, which is when medication errors are most likely to occur 1

Common Pitfalls to Avoid

• Telephone or informal consultations without documentation create gaps in the medical record and increase risk of medication errors 1
• Failing to communicate changes to the hospice team can result in conflicting medication administration, particularly problematic given that hospice nurses often manage anticipatory prescribing 1
• Not documenting the decision-making process for a non-verbal patient leaves the record vulnerable to questions about informed consent and appropriate surrogate involvement 1

The visit note should function as both a clinical record and a communication tool, ensuring all members of the care team—including hospice nurses who may be administering medications at home—have access to current, accurate medication information 1.