What are the key components to include in a SOAP (Subjective, Objective, Assessment, and Plan) note for a patient with dementia undergoing hospice recertification?

Dementia Hospice Recertification SOAP Note

Subjective

Document complete functional dependence and decline:

• Record total assistance required for all activities of daily living (ADLs): inability to dress, bathe, toilet, transfer, or feed without complete assistance 1
• Note weight loss or nutritional compromise despite assisted feeding 1
• Document inability to communicate meaningfully, such as loss of ability to speak more than 6 words or inability to recognize family members 1
• Record rapid day-to-day deterioration and irreversible decline in function 1
• Obtain informant report from surrogate decision-maker regarding cognitive, functional, and behavioral changes using validated tools like the AD8, IQCODE, or NPI-Q 2

Capture behavioral and neuropsychiatric symptoms:

• Document agitation, restlessness, or distress requiring ongoing intervention 1
• Note any behavioral changes that indicate terminal phase progression 3

Objective

Functional assessment using validated instruments:

• Use the Functional Assessment Staging Tool (FAST) to document stage 7 characteristics (inability to ambulate, sit up, smile, or hold head up independently) 2
• Document complete bedbound status or inability to ambulate independently 1
• Record Pfeffer Functional Activities Questionnaire (FAQ) scores showing severe impairment 2

Physical examination findings indicating terminal phase:

• Document inability to swallow, indicating terminal phase 1
• Record changing breathing patterns: gurgling, rattly breathing, or irregular respirations 1
• Note decreased consciousness or rapid deterioration 3
• Document weight and nutritional status objectively 1

Cognitive assessment:

• While formal cognitive testing may not be feasible in advanced dementia, document observed cognitive status and inability to engage in any cognitive activities 4
• Note complete loss of self-care abilities 4

Assessment

Establish continued hospice eligibility:

• Confirm end-stage dementia with life expectancy ≤6 months based on: complete ADL dependence, inability to communicate meaningfully, nutritional compromise, and presence of medical complications 1, 5
• Document that the patient meets criteria for terminal phase with rapid deterioration, inability to swallow, or changing breathing patterns 1
• Note that goals of care focus on comfort, quality of life, and symptom management rather than life prolongation 1

Address comorbidities and complications:

• Assess for undiagnosed pain, as this is a common cause of behavioral changes even when patients cannot verbally communicate discomfort 3, 4
• Document any medical complications that support continued hospice appropriateness 5

Plan

Symptom management approach:

• Implement proactive pain assessment and management using behavioral pain scales, as undiagnosed pain is common and manifests as behavioral changes 3, 4
• Document nutritional support approach: comfort feeding by hand rather than tube feeding 1
• Record hydration management: fluids as tolerated, recognizing artificial hydration is not indicated in terminal phase 1
• Address constipation proactively as it significantly impacts quality of life 4

Medication management:

• Reassess dementia medications (memantine, acetylcholinesterase inhibitors) for continued benefit versus side effects in context of advanced disease 4
• Avoid unnecessary medications and focus on comfort-directed pharmacotherapy 3, 4

Advance care planning documentation:

• Record advance care planning discussions with surrogate decision-maker about preferences for end-of-life care, including decisions to forgo hospitalization, tube feeding, or aggressive interventions 1
• Document that surrogate decision-maker has been provided comprehensive information about dementia progression, expected complications, and available care options 3

Avoid inappropriate interventions:

• Document plan to avoid tube feeding, excessive laboratory tests, physical restraints, and intravenous medications when oral/subcutaneous routes suffice 4
• Confirm discontinuation of all non-comfort interventions as death approaches 4

Caregiver support:

• Document provision of education on dementia progression, end-of-life care, symptom management strategies, and what to expect as death approaches 4
• Connect caregivers to support resources: respite services, support groups, and help hotlines 4

Follow-up plan:

• Schedule regular reassessment of symptoms and functional status 3
• Establish protocols for symptom management that can be implemented by all caregivers 3