Hospice Admission Note (Initial and Comprehensive Assessment)

Encounter Information

Patient Name: [Patient full legal name]

Date of Birth: [DOB]

MRN: [MRN]

Location of Care: [Home / ALF / SNF / Hospital / Hospice IPU]

Address (if home-based): [Home address]

Date and Time Patient Seen: [Date and time]

Date and Time Note Signed: [Date and time]

Disciplines Present: [List all disciplines present for this visit]

Referral Source: [Referral source name, role, and organization]

Level of Care at Admission: [Routine Home Care / General Inpatient / Inpatient Respite / Continuous Home Care]

Initial Nursing Assessment (48h requirement): [Completed / In Progress / Not Yet Started]

Comprehensive Assessment (5-day requirement): [Completed / In Progress / Not Yet Started]

Preferred Language: [Language]; Interpreter Used: [Yes / No / Not needed]

Sensory Limitations: [Vision / Hearing / Speech / None]

Decision-Making Capacity: [Has capacity / Lacks capacity for some decisions / Lacks capacity / Fluctuating] — [Brief basis of assessment]

(If required information cannot be obtained, document "unable to obtain" with reason and follow-up plan.)

Hospice Election, Rights, and Consents

• Election Statement Completed: [Yes / No] — Effective date and time: [Date and time] (If no, document barriers and plan)
• Attending Clinician Identified: [Yes / No] — [Name and credentials]
• Informed that Hospice is Palliative (not Curative): [Yes / No] — [Documentation of patient/caregiver understanding]
• Patient Rights and Responsibilities Provided (verbal and written): [Yes / No] — [Format and accommodations used]
• Signature for Receipt of Rights Notice: [Yes / No] (If no, document explanation and plan)

Advance Directives and Decision-Makers:

• Healthcare Proxy/Surrogate: [Name, relationship, contact information]
• Existing Documents: DNR [Yes / No / Unknown]; POLST [Yes / No / Unknown]; Advance Directive [Yes / No / Unknown] — [Retrieval plan if unavailable]

Election Addendum (Non-covered or Unrelated Items): [Not applicable / Requested and pending / Provided with date]

(Do not infer code status or treatment preferences. Document what was asked, what was decided, and what remains undecided.)

Hospice Eligibility Context

Terminal Diagnosis: [Terminal diagnosis]

Related Conditions and Key Comorbidities: [Conditions affecting prognosis or symptom burden]

Clinical Decline Narrative: [Summarize decline over recent weeks to months: hospitalizations, ED visits, infections, weight or appetite changes, functional and ADL decline, cognitive changes, increasing symptom burden, intolerance or declination of disease-directed therapy. Attribute caregiver-reported information, e.g., "per daughter."]

Objective Prognostic Indicators: Performance status [PPS or KPS score and date]; ADL dependence level [Level]; Disease-specific severity markers [Details]

Indicators of Imminent Death: [Document findings if present, or state "No current indicators of imminent death noted"]

Chief Concern and Goals for Hospice

[Brief statement of why hospice now. Document patient and family goals and priorities such as comfort, staying home, avoiding hospitalization, or specific fears. Include one direct quote if it clarifies values.]

Current Illness Narrative

[Narrative of symptom story over the last 24–72 hours and what prompted admission or referral. Include current treatments and response, patient's expressed understanding of illness and prognosis supported by patient statement or teach-back, and key caregiver observations.]

Symptom Assessment

Pain

Screening Performed: [Yes / No] — Tool: [Tool name]; Date and time: [Date and time]; Severity: [Rating]

Comprehensive Assessment (if pain present): [Location, severity, character, duration, frequency, relieving and worsening factors, impact on function]

Dyspnea

Screening Performed: [Yes / No]; Dyspnea Present: [Yes / No]

Treatment (if present): [Opioids / Oxygen / Non-pharmacologic measures] — [Initiated / Continued]; Patient response: [Accepted / Declined / Unable to tolerate]

Bowel Function

Opioids Initiated or Continued: [Yes / No]

Bowel Regimen: [Initiated / Continued / Not indicated] (If not initiated with opioid use, document clinical rationale)

Other Symptoms

[Document presence, severity, and interventions for applicable symptoms: nausea/vomiting, anxiety, agitation/delirium, depression, insomnia, fatigue, anorexia/cachexia, secretions, pruritus, edema, or other symptoms identified]

(If patient cannot self-report, document the observational tool used and source of collateral information.)

Functional and Cognitive Status

Performance Status: [PPS or KPS score and date]

ADLs: Bathing [Independent / Supervision / Partial assist / Full assist]; Dressing [Independent / Supervision / Partial assist / Full assist]; Toileting [Independent / Supervision / Partial assist / Full assist]; Transfers [Independent / Supervision / Partial assist / Full assist]; Continence [Continent / Incontinent / Mixed]; Feeding [Independent / Supervision / Partial assist / Full assist]

Mobility: [Ambulatory / Ambulatory with device / Chairbound / Bedbound]; Assistive devices: [Devices]; Falls history: [Details]

Cognition and Communication: Orientation [Alert and oriented x4 / x3 / x2 / x1 / disoriented]; Delirium risk [Low / Moderate / High]; Aphasia [Yes / No]; Ability to participate in decisions [Able / Limited / Unable]

(If patient lacks decision-making capacity, document assessment basis and identify surrogate decision-maker.)

Swallowing and Aspiration Risk: [Risk factors and current status]

Nutrition and Hydration: [Intake pattern, weight trend if available, hydration status]

Skin and Wounds: [Integrity, pressure injury risk, existing wounds with stage and location]

Sleep Pattern: [Sleep quality and disturbances]

Medication Review

Reconciliation Status: [Complete / Partial] — Sources: [Pill bottles / Facility MAR / Discharge summary / Caregiver list / Pharmacy records]

Medications:

• Scheduled: [List name, dose, route, frequency]
• PRN: [List name, dose, route, indication]
• OTC and Supplements: [List]

Safety Review: Effectiveness [Per patient/caregiver report]; Side effects [Reported or observed]; Interaction or duplication concerns [Yes / No with details]; Monitoring needs [What to monitor]

Allergies and Intolerances: [Agent and reaction type]

(If reconciliation is incomplete, document reason, records requested, and interim safety plan.)

Objective Assessment

[General appearance and distress level. Include vital signs only if clinically indicated. Focused examination findings by relevant systems aligned with terminal condition and symptoms. Document any lines, drains, ostomies, catheters, oxygen equipment, or wounds.]

Psychosocial Assessment

[Living situation and who is present in the home. Identify primary caregivers with willingness, ability, health limitations, availability, burden risk, and respite needs. Document financial or insurance barriers, access to food, utilities, and transportation. Include mental health and coping for patient and caregivers, substance use concerns if relevant, family dynamics, conflict, communication preferences, cultural considerations, and legal or guardianship issues.]

Neglect/Abuse Risk Screening: [Screening performed — findings, observations, and actions per policy]

Spiritual and Existential Needs

Discussion Status: [Patient asked about spiritual or existential concerns — discussion occurred / declined]

[Document only what patient wishes to share. Note indicators of spiritual distress such as concerns about meaning, guilt, fear, or hopelessness if present.]

Desired Supports: [Chaplain visit / Community clergy / Rituals / Music / Prayer / Cultural practices / None requested]

Environment and Safety

[Fall risk factors and home layout hazards. Fire and oxygen safety with smoking exposure status. Medication storage and controlled substance safety plan. Staff access issues such as lockbox or pets. Emergency preparedness including who to call, backup caregiver plan, and equipment power needs.]

Bereavement Risk Assessment

[Key support persons and relationships. Prior losses, mental health or substance use history, complicated grief risk factors such as limited support network, high conflict, or dependent relationships. Cultural or spiritual factors affecting grief.]

Bereavement Plan: [Routine follow-up / Elevated follow-up] — Rationale: [Brief rationale]; Referrals: [Bereavement counselor / Community resources / None indicated]

Assessment and Plan

(Problem-oriented structure ordered by severity and priority. Include only active problems.)

Problem 1: [Problem or Diagnosis]

Supporting Findings: [Key symptoms, objective data, functional impact, trajectory]

Goal: [Goal stated in patient or family terms]

Interventions: [Medications with dose, route, frequency and whether new, continued, or changed; non-pharmacologic measures; discipline visits with frequency; DME and supplies; caregiver education topics]

Follow-up: [What will be reassessed, when, and escalation plan]

Problem 2: [Problem or Diagnosis]

(Repeat structure for each additional problem as needed.)

Preferences and Advance Care Planning:

• CPR Preference: [Full code / DNR / Undecided / Declined to discuss]
• Other Life-Sustaining Treatment Preferences: [Details or undecided]
• Hospitalization Preference: [Avoid hospitalization / Hospitalize if needed / Undecided]

(If patient refused to discuss, document refusal and plan to revisit.)

Interdisciplinary Referrals: [Social work / Chaplain / Aide / Therapy / Dietitian / Volunteer / Bereavement counselor / Community resources]

Care Coordination: [Coordination with facility staff, attending clinician, hospice medical director, pharmacy, DME vendors as applicable]

(Document "screened; not present" for standardized admission elements assessed and not found.)

Pending Items

(Include this section only if the comprehensive assessment is not fully complete.)

• Component: [Pending component] — Reason: [Time constraints / Patient fatigue / Unavailable caregiver / Awaiting records] — Assigned Discipline: [Discipline] — Expected Completion: [Date within required timeframe] — Interim Plan: [Risk mitigation actions]

Communication and Authentication

Notifications: [Attending clinician / Hospice medical director / Facility nurse] — [Date, time, and method]

Education Provided: [After-hours contact number, when to call, medication safety, symptom escalation guidance, equipment use] — Understanding: [Teach-back summary or acknowledgment]

Signature: [Name, credentials] — Date and Time Signed: [Date and time]

(All contributors sign and time-stamp entries per policy.)