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, continued terminal prognosis with life expectancy ≤6 months, and confirm the patient meets Medicare hospice eligibility criteria through either dialysis discontinuation or continued dialysis with multiple comorbidities and declining status. 1

Subjective Component

Document the following patient-reported elements:

• Current symptom severity using validated tools (ESAS-R or iPOS-R for renal-specific assessment), including pain intensity, location, character, and impact on daily activities 1
• Functional status changes since last certification period, specifically noting decline in activities of daily living, mobility, and self-care capacity 1
• Patient and family understanding of current disease trajectory and goals of care 1
• Symptom burden including fatigue, dyspnea, nausea, pruritus, restless legs, and anxiety that are common in ESRD 2, 3
• Quality of life assessment addressing physical, psychosocial, and existential concerns 2

Objective Component

Include these measurable clinical indicators:

• GFR <15 mL/min/1.73 m² if not on dialysis, which is a clinical indicator of terminal ESRD 1
• Dialysis status: If continuing dialysis, document it as a palliative comfort measure to achieve patient-centered goals (e.g., symptom control, attending important life events) rather than life-prolonging treatment 1
• Vital signs and weight trends showing progressive decline or volume overload 4
• Functional performance status using objective scales (e.g., Karnofsky or Palliative Performance Scale) 1
• Laboratory values if available: potassium, BUN, creatinine, albumin (protein-energy wasting indicator) 4
• Comorbidity burden: Document multiple comorbidities such as heart failure, diabetes with complications, cognitive impairment, or physical disability that compound the terminal prognosis 1, 2

Assessment Component

Provide clear clinical reasoning:

• Reaffirm terminal prognosis with life expectancy ≤6 months based on progressive functional decline, worsening symptom burden, and multiple comorbidities 1
• Justify continued hospice eligibility under Medicare criteria, explicitly stating whether the patient has discontinued dialysis or continues palliative dialysis with declining status 1
• Symptom control status: Rate current management effectiveness and identify uncontrolled symptoms requiring intervention 1
• Goals of care alignment: Confirm that current care plan matches patient's documented wishes and advance directives 1
• Psychosocial and spiritual needs: Address depression, anxiety, existential suffering, and family caregiver burden 2, 3

Plan Component

Outline specific interventions for the recertification period:

Symptom Management

• Continue or adjust medications for pain, nausea, pruritus, dyspnea, and other uremic symptoms, ensuring all medications are dose-adjusted for renal function 1
• Discontinue non-beneficial medications including statins and vitamins unless used for symptom control 1
• Hospice nursing visit frequency based on symptom needs and patient-centered care goals 1

Advance Care Planning

• Confirm code status (typically DNR/DNI in hospice) and review advance directives 1
• Document goals of care discussions aligned with current clinical status, ensuring shared decision-making is clearly recorded 1
• Complete or update medical orders for life-sustaining treatment (MOLST/POLST) 1

Interdisciplinary Team Coordination

• Hospice team involvement: Specify roles for nursing, social work, chaplaincy, and volunteer services based on identified needs 1
• Dialysis coordination: If continuing palliative dialysis, coordinate with dialysis center regarding symptom-focused approach and hemodynamic tolerance 1, 4
• Family support: Address caregiver burden and provide bereavement preparation 3

Quality Metrics Documentation

• Symptom assessment scores using validated tools at regular intervals 1
• Documented shared decision-making and advance care planning discussions 1
• Completion of advance directives and medical orders 1

Critical Pitfalls to Avoid

Common documentation errors that jeopardize recertification:

• Failing to justify continued dialysis as a comfort measure rather than life-prolonging treatment when patient remains on dialysis 1
• Inadequate documentation of decline since last certification period—Medicare requires evidence of progression toward death 1
• Missing symptom assessment scores—use validated tools rather than subjective descriptions alone 1
• Lack of goals of care documentation—must show alignment between patient wishes and current care plan 1
• Omitting comorbidity impact—for patients continuing dialysis, multiple comorbidities and declining status must be clearly documented to meet eligibility 1

The nephrology community recognizes that supportive care should be integrated into routine ESRD management, with improved partnerships with specialist palliative care colleagues for complex patients transitioning to end-of-life care 5. Despite ESRD patients having reduced life expectancy and high symptom burden, hospice remains underutilized in this population, making thorough documentation essential for ensuring continued access to appropriate end-of-life care 2, 3.