What are the key components of a SOAP note for recertification of a patient with End Stage Renal Disease (ESRD) in hospice care?

ESRD Hospice Recertification SOAP Note

For hospice recertification of an ESRD patient, document progressive functional decline, worsening symptom burden, and continued terminal prognosis with life expectancy ≤6 months, emphasizing that the patient meets Medicare hospice eligibility criteria through either dialysis discontinuation or continued dialysis with multiple comorbidities and declining status. 1

Subjective

Patient/Family Report:

• Document current symptom severity using validated tools (ESAS-R or iPOS-R for renal-specific assessment) 1
• Assess pain intensity, location, character, and impact on daily activities
• Evaluate uremic symptoms: nausea, vomiting, pruritus, fatigue, dyspnea, anorexia 2, 3
• Screen for depression, anxiety, and cognitive impairment (common in ESRD) 2
• Document patient/family understanding of prognosis and goals of care 1
• Assess quality of life changes since last certification period
• If on dialysis: document tolerance (hypotension, cramping, post-dialysis recovery time) 4
• If dialysis discontinued: document timing and reason for withdrawal 1

Objective

Functional Status:

• Karnofsky Performance Status or Palliative Performance Scale score (typically ≤50% for hospice eligibility)
• Document decline in activities of daily living (ADLs) and instrumental ADLs
• Weight changes and nutritional status 2
• Frequency of hospitalizations in past 60-90 days 5

Clinical Indicators of Terminal ESRD:

• GFR <15 mL/min/1.73 m² if not on dialysis 1
• Uremic encephalopathy manifestations: confusion, asterixis, myoclonus, seizures 4
• Refractory fluid overload with pulmonary edema despite management
• Pericarditis or uremic pericardial effusion
• Intractable hyperkalemia (>7 mEq/L) or metabolic acidosis 4
• Severe anemia unresponsive to erythropoietin 5
• Platelet dysfunction with bleeding diathesis

Comorbid Conditions Affecting Prognosis:

• Cardiovascular disease: heart failure (NYHA Class III-IV), recent MI, arrhythmias 4, 5
• Sepsis or recurrent infections 5
• Malignancy 5
• Advanced liver disease
• Severe malnutrition (albumin <2.5 g/dL)
• Dementia or stroke with functional impairment 2
• Diabetes with end-organ complications 5

Vital Signs and Physical Exam:

• Blood pressure trends (hypotension suggests poor prognosis)
• Volume status assessment
• Mental status examination
• Skin integrity (uremic frost, ecchymoses, pressure injuries)
• Cardiopulmonary examination findings

Assessment

Primary Diagnosis: End-Stage Renal Disease (Stage 5 CKD, GFR <15 mL/min/1.73 m²) 1

Terminal Prognosis Justification:

• Document specific criteria supporting ≤6 months life expectancy 1, 2
• Progressive functional decline over certification period
• Increasing symptom burden despite optimal management 1
• Multiple hospitalizations (≥2 in past 90 days suggests poor prognosis) 5
• Patient meets criteria for continued hospice appropriateness

For patients continuing dialysis concurrently with hospice:

• Justify palliative dialysis as comfort measure to achieve patient-centered goals (e.g., symptom control, attending important life events) 1
• Document that dialysis frequency/duration modified for comfort rather than life prolongation 1
• Note this represents goal-concordant care aligned with patient wishes 1

Comorbid Conditions: List all active diagnoses affecting prognosis and symptom burden 5

Current Symptom Burden: Prioritize symptoms impacting quality of life 1, 2

Plan

Hospice Recertification:

• Patient continues to meet Medicare hospice eligibility criteria for terminal ESRD
• Anticipated prognosis remains ≤6 months if disease follows expected course
• Continue interdisciplinary hospice services 2, 3

Symptom Management:

• Pain: Specify analgesic regimen with dose adjustments for renal clearance 4
• Uremic symptoms: Antiemetics, antihistamines for pruritus, appetite stimulants as appropriate
• Dyspnea: Opioids, oxygen, positioning
• Anxiety/depression: Psychotropic medications with renal dosing, counseling support 2
• Implement systematic symptom assessment at each visit using validated tools 1

Dialysis Management (if applicable):

• Continue palliative dialysis schedule (specify frequency) 1
• Modify ultrafiltration goals for comfort rather than aggressive volume removal 4
• Monitor for dialysis intolerance requiring schedule adjustment 4
• Coordinate timing with hospice nursing visits

Advance Care Planning:

• Confirm code status (typically DNR/DNI in hospice)
• Review and update advance directives 1
• Document surrogate decision-maker 1
• Ensure goals of care discussions documented and aligned with current clinical status 1

Interdisciplinary Team Involvement:

• Hospice nursing: Frequency of visits based on symptom needs
• Social work: Patient/family psychosocial support, bereavement preparation 3, 6
• Chaplain: Spiritual care assessment and support 6
• Hospice aide: Personal care assistance
• Volunteer services as appropriate
• Nephrology consultation available for complex symptom management 2

Medication Review:

• Discontinue non-beneficial medications (statins, vitamins unless for symptom control)
• Ensure all medications appropriately dose-adjusted for renal function 4
• Avoid nephrotoxic agents that could worsen uremic symptoms 4

Family/Caregiver Support:

• Assess caregiver burden and provide respite care as needed 3
• Education regarding disease trajectory and expected changes 3
• Bereavement support planning 6

Quality Metrics Documentation:

• Documented shared decision-making and advance care planning discussions 1
• Completion of advance directives and medical orders 1
• Symptom assessment scores using validated tools 1
• Patient-centered care goals identified and addressed 1

Follow-up:

• Next hospice visit scheduled within [specify timeframe based on stability]
• 24/7 hospice on-call availability for symptom crises
• Plan for transition to continuous care or inpatient hospice if symptoms become unmanageable at home