What are the primary recommendations for a patient with chronic obstructive pulmonary disease (COPD) undergoing hospice recertification?

Hospice Recertification SOAP Note for COPD Patient

Subjective

Document continued terminal prognosis with life expectancy ≤6 months if disease follows natural course. 1 The patient must demonstrate progressive decline despite optimal therapy, severe functional impairment, and increasing healthcare utilization to meet recertification criteria. 1

Key Elements to Document:

• Dyspnea severity: Disabling dyspnea at rest, poorly responsive to bronchodilators, with decreased functional capacity 1
• Functional decline: Inability to perform activities of daily living, increasing dependence on caregivers 1
• Recent healthcare utilization: Document emergency department visits or hospitalizations for pulmonary infections and/or respiratory failure since last certification 1
• Symptom burden: Assess dyspnea, pain, anxiety, depression, fatigue, poor nutrition, cough, and insomnia 2, 3
• Patient/family understanding: Confirm DNR/DNI status and understanding that hospice provides comfort care only 1

Objective

Required Clinical Indicators:

• Pulmonary function: FEV1 <30% predicted (post-bronchodilator) 1
• Gas exchange abnormalities:
  • Hypoxemia at rest on supplemental oxygen: PaO2 ≤55 mmHg or SaO2 ≤88% 1
  • Hypercapnia: PaCO2 ≥50 mmHg 1
• Cardiac complications: Right heart failure secondary to pulmonary disease (cor pulmonale) 1
• Vital signs: Document respiratory rate, oxygen saturation, heart rate, blood pressure
• Physical examination findings: Accessory muscle use, pursed-lip breathing, cyanosis, peripheral edema, cachexia 4
• Weight: Document unintentional weight loss if present 2

Functional Status:

• Performance status: Document Karnofsky or Palliative Performance Scale score
• ADL dependence: Specify assistance needed for bathing, dressing, toileting, transfers, eating 1

Assessment

Patient continues to meet hospice eligibility criteria for end-stage COPD with terminal prognosis. 1 The physician certifying hospice eligibility certifies that prognosis is more likely than not less than 6 months if disease runs its natural course, not a "guarantee" of death within 6 months. 1

Clinical Justification:

• Progressive disease despite optimal medical management including [specify current medications] 1
• Severe airflow obstruction with FEV1 <30% predicted 1
• Persistent hypoxemia/hypercapnia despite supplemental oxygen 1
• Recurrent exacerbations requiring [number] hospitalizations/ED visits in past [timeframe] 1
• Cor pulmonale present [if applicable] 1
• Severe functional impairment with dependence in [number] ADLs 1

Symptom Assessment:

• Dyspnea: [Severity and impact on function] 2
• Pain: [Location, severity, current management] 2
• Anxiety/Depression: [Presence and severity] 2
• Other symptoms: Fatigue, cough, insomnia, poor appetite 2, 3

Plan

Symptom Management:

• Continue supplemental oxygen for comfort, not to prolong life 1
• Bronchodilators: Continue current regimen for symptom relief 2
• Opioids: [Specify dose/frequency] for refractory dyspnea 2, 3
• Anxiolytics: [Specify medication] for anxiety/panic if present 2
• Other medications: Address pain, depression, insomnia as needed 2, 3

Interdisciplinary Team Involvement:

• Registered nurse: Regular visits to assess symptom control, functional status, and caregiver needs 1
• Social worker: Provide psychosocial support to patient and family 1
• Chaplain: Spiritual support as desired 1
• Home health aide: Assistance with personal care 1

Advance Care Planning:

• DNR/DNI status confirmed: [Document current status] 1
• Preferences for future exacerbations: Patient/family understand no hospitalization for acute events, comfort measures only 1
• Preferred place of death: [Document if discussed] 2

Monitoring:

• Hospice nurse visits [specify frequency] to reassess symptoms and adjust medications 1
• Physician availability for urgent symptom management 1
• 24/7 on-call support for patient/family 1

Common Pitfalls to Avoid:

• Do not delay palliative interventions waiting for absolute certainty of 6-month prognosis—COPD trajectory is unpredictable 2, 4
• Do not overlook depression and anxiety, which are common and treatable in advanced COPD 2
• Do not continue disease-modifying therapies that no longer align with comfort-focused goals 2
• Ensure reliable oxygen delivery system is in place to prevent distressing hypoxemia 1

Recertification period: [Specify 60 or 90 days per Medicare guidelines]

Next physician evaluation: [Date within required timeframe]