General Inpatient Hospice Admission/Progress Note (GIP)

General Inpatient Hospice (GIP) Note

Date/Time: [date and time of service]

Patient: [name, DOB, MRN]

Hospice Program: [program name]

Location: [facility, unit]

Note Type: [Admission / Daily Progress / Significant Change]

Level of Care: General Inpatient (GIP)

Author: [name, credentials]

Source of Information: [patient / family / nursing staff / chart review] (Note reliability limitations if present.)

Clinical Summary and History

Chief Concern: [One-sentence reason for this encounter]

Clinical Summary: [Terminal diagnosis, key comorbidities impacting symptom management, functional status, and why inpatient hospice is required today] (Keep to 1–3 sentences to orient the reader.)

History: [Narrative tailored to note type] (For Admission: describe precipitating crisis including onset, trajectory, severity, and triggers; prior care setting; interventions already attempted and why they were ineffective, intolerable, not feasible to administer/monitor, or unavailable. For Daily Progress: document interval changes since last note including symptom trends over past 24 hours, breakthrough episodes, PRN use with response and adverse effects, and any route/dose changes; if PRN data are unavailable, explicitly note the gap. For Significant Change: describe the event, trigger, rapid clinical changes, and emergent interventions.)

Goals of Care: [Current comfort-focused goals, decision-maker and capacity status, code status, and summary of discussions held today with outcomes] (Include on Admission and update when changes occur. Use direct quotes for patient/family values when available. If not yet clarified, state reason and plan to address.)

Symptom Assessment

(Focus on active comfort problems. At minimum address pain, dyspnea, agitation/delirium, and nausea. Add other symptoms relevant to the patient's condition as applicable. For each symptom, document severity, patient report or nonverbal indicators if unable to self-report, and response to prior interventions. Include objective findings only when they guide comfort interventions. If examination is limited by comfort goals or patient condition, state the reason.)

Active Symptoms: [For each active comfort problem: symptom name, severity/pattern, patient-reported qualities or nonverbal indicators, response to prior interventions including adverse effects, and current route considerations]

Pertinent Objective Observations: [General appearance and level of distress, and other focused findings that inform comfort interventions] (Omit routine vitals that do not influence the plan.)

Assessment and Plan

(Organize by problem, starting with the GIP-qualifying symptom(s), then other active comfort issues in order of severity. For each problem, include assessment with clinical reasoning and actionable plan. Do not list problems not being actively managed for comfort.)

[GIP-qualifying symptom]: [Current status and assessment] | Plan: [Medications with route/dose and changes made today, nonpharmacologic measures, nursing actions/monitoring frequency, measurable response criteria, and escalation/de-escalation triggers]

[Other active comfort issues as applicable]: [Current status and assessment] | Plan: [Medications, nonpharmacologic measures, monitoring, response criteria, triggers]

GIP Medical Necessity

Admission Justification

(Include for Admission notes.)

Primary symptom(s) requiring GIP and severity: [description]

Why symptom management is not feasible in another setting: [need for frequent skilled assessment, frequent medication titration, routes/therapies not available elsewhere, and/or safety risks tied to symptoms] (Be explicit.)

Prior measures attempted and why they failed: [ineffective / intolerable effects / unable to administer or monitor / unavailable]

Immediate inpatient plan and intensity: [high-frequency reassessment, titration protocol, continuous infusion, bedside monitoring as applicable]

Ongoing Daily Justification

(Include for Daily Progress and Significant Change notes.)

GIP remains appropriate today because: [symptoms not yet controlled or stabilized / continued requirement for frequent titration or monitoring / breakthrough crises requiring rapid intervention]

Inpatient-level interventions performed today: [what is actively being done that requires inpatient intensity]

Criteria for step-down: [targets for symptom control, route stability, monitoring frequency manageable in a lower level of care]

(Do not justify GIP solely by caregiver inability, placement delays, or social factors unless explicitly linked to symptom management feasibility and intensity requirements.)

Discharge Planning

(Include daily once stabilization is plausible.)

Anticipated next level of care: [routine home hospice / continuous home care / SNF / inpatient facility / other]

Clinical criteria for step-down: [symptom control targets, route stability, safety considerations]

Target timeframe: [estimated timeframe if known]

Current barriers and plan to address: [equipment, caregiver training/availability, pharmacy access, placement, transport; specific actions and responsible parties]

Author Electronic Signature: [name, credentials, date/time signed]

(Missing information: For required elements such as decision-maker, code status, GIP justification, or symptom assessment, use "Unknown or not assessed today because [reason]; plan: [next steps]." Inference guidance: Document observed comfort or distress based on appearance/behavior; clearly separate patient/family report from clinician interpretation. Copy-forward: Update all imported text to reflect today's condition, PRN use, and plan.)