Hospice Discharge, Revocation, or Transfer Summary

Document Header

Patient: [Full name] | DOB: [MM/DD/YYYY] | MRN: [Medical record number]

Attending physician during hospice episode: [Name, credentials, contact]

Location at discharge: [Home / Assisted living / SNF / Hospital / Other]

Hospice agency: [Agency name] | Main contact: [Phone] | After-hours: [Phone] | Fax: [Fax] | Address: [Address]

Key hospice team members involved in care:

• [RN case manager: Name, contact]
• [Hospice medical director or covering clinician: Name, contact]
• [Social worker: Name, contact]
• [Chaplain/Spiritual care: Name, contact] (Include if involved in care)
• [Other disciplines as applicable: PT/OT, HHA/CNA, bereavement]

Type of End-of-Service: [Discharge / Revocation / Transfer]

Hospice admission/election effective date: [MM/DD/YYYY] (If not confirmed, enter "Pending confirmation")

Discharge/Revocation/Transfer effective date and time: [MM/DD/YYYY HH:MM] (If not confirmed, enter "Pending confirmation")

Date of last face-to-face clinical contact: [MM/DD/YYYY] | Discipline: [RN / NP / MD / SW / Other] (If not confirmed, enter "Pending confirmation")

Disposition and Reason for End-of-Service

Synopsis: [One sentence stating patient discharged alive on date, reason, general condition at discharge, and receiving clinician or facility]

Post-hospice disposition destination: [Home with self/family / Home with home health / SNF / Inpatient facility / New hospice / Other]

Primary responsible clinician/team after hospice ends: [Name, role, organization, contact]

Revocation Details

(Complete only if Type of End-of-Service = Revocation)

• Initiated by: [Patient / Legal representative: name and relationship]
• Revocation statement: [Signed statement on file at: location in record / Pending signed statement] (If only verbal request, document written statement is pending)
• Date/time revocation received: [MM/DD/YYYY HH:MM]
• Effective date/time of revocation: [MM/DD/YYYY HH:MM]
• Patient-stated reason: [Reason in neutral language or brief direct quote]

Discharge Details

(Complete only if Type of End-of-Service = Discharge)

• Primary discharge reason: [Moved out of service area / No longer terminally ill / Discharge for cause]
• Supporting clinical facts: [Objective summary supporting the discharge reason]
• (If no longer terminally ill) Clinical basis and discharge planning: [Evidence for prognosis change, discussions held, post-discharge plan]
• (If discharge for cause) Behaviors/events with dates: [Objective events and timeline]
• (If discharge for cause) Mitigation efforts and timeline: [Interventions, education, care conferences, results]
• (If discharge for cause) Confirmation not due to use of necessary services: [Statement of compliance]
• (If discharge for cause) Required notifications completed: [Notices sent, dates, recipients]

Transfer Details

(Complete only if Type of End-of-Service = Transfer)

• Transfer type: [To another hospice / To Medicare/Medicaid-certified facility]
• Receiving organization: [Name, contact information]
• Acceptance status: [Accepted / Pending acceptance / Declined] (If pending, document follow-up plan)
• Gap in services anticipated: [No gap anticipated / Gap anticipated: describe and safety plan]
• Effective date/time of transfer: [MM/DD/YYYY HH:MM]

Required Documentation and Notices

• (If hospice-initiated discharge) Written discharge order: [Author, date, location in record]. Attending physician consulted: [Yes: date/method / No: reason / N/A: no attending involved]
• (If revocation) Signed revocation statement: [Date/time received], Signer: [Name/role], Effective date on statement: [MM/DD/YYYY], Copy provided to patient/representative: [Yes / No]
• (If transfer between hospices) Signed transfer statement: [On file / Pending], includes prior hospice name, new hospice name, and effective date
• (If beneficiary notices apply) Notice of Medicare Non-Coverage/financial liability notice: [Provided / Not applicable], Date: [MM/DD/YYYY], Delivery method: [In person / Mail / Electronic], Expedited review/appeal requested: [Yes: details / No]

Clinical Summary

[Terminal diagnosis and key related conditions influencing care. Significant events during hospice episode including crises, hospitalizations, major medication changes, and symptom management highlights. Relevant psychosocial or caregiver context that impacts ongoing care.] (One to two concise paragraphs; write for clinicians new to the case)

Status at End of Service

Functional Status: [PPS or equivalent score], [Ambulatory status], [ADL dependency level]

Cognition/Communication: [Alertness], [Capacity considerations], [Ability to self-report symptoms]

Current Symptoms: Pain: [score/description], Dyspnea: [severity], Anxiety/agitation: [severity], Nausea: [severity], Constipation: [status], Appetite: [status], Fatigue: [severity], Other: [active symptoms]

Key Physical Findings: [Only findings that change management: edema, respiratory distress signs, wounds, pressure injuries, etc.]

Devices/Treatments in Place: [Oxygen: method/flow], [Catheters], [Drains], [Enteral feeds], [Wound care devices], [Other]

Safety Considerations: [Falls risk], [Aspiration risk], [Medication safety concerns], [Caregiver reliability issues]

(If any element was not assessed, explicitly state "Not assessed" for that element)

Active Problems and Transition Plan

(List problems by clinical priority. For each, include current status, what was effective under hospice, post-hospice owner, and escalation guidance. For short stays or minimal symptom complexity, this section may be brief.)

• [Problem]: [Current status]. Effective under hospice: [Interventions/meds/supports]. Post-hospice owner: [Name, role, contact]. Escalation: [When/how to escalate; ED criteria]
• [Problem]: [Current status]. Effective under hospice: [Interventions]. Post-hospice owner: [Owner]. Escalation: [Guidance]

(Add additional problems as needed using same format)

Medications

Medication reconciliation: Sources: [Hospice MAR / Caregiver report / Facility MAR / Pharmacy records]. Status: [Complete / Partial: explain limitations / Unable to fully reconcile: explain]

Reconciled medication list:

• [Medication – dose, route, frequency – indication – Continue/Stop/Start/PRN] (Flag if high-risk: opioid, benzodiazepine, anticoagulant, insulin, antipsychotic)
• [Medication – dose, route, frequency – indication – status]

Medication coverage and supply disposition: [Identify hospice-supplied medications and post-hospice plan: transferred to receiving entity / returned to pharmacy / left with patient with coverage change education / disposed]. Ongoing prescriber for symptom medications: [Name, role, contact]

Controlled substances: Safe-use and disposal education provided: [Yes / No]. Disposition of remaining controlled medications: [Left in home with instructions / Disposed onsite per policy / Take-back program instructions provided]. Date/time: [MM/DD/YYYY HH:MM]. Participants present: [Names/roles]. [Document any refusal or inability to safely manage medications] (Do not assume disposal occurred; document method, date/time, and participants)

Equipment and Supplies

DME in use and disposition:

• [Item] – [Remains in home under new payer / Pickup scheduled: date, vendor / Transferred to receiving entity]
• [Item] – [Disposition] (If pickup not scheduled, state coordination is pending and document interim safe-use instructions)

Bridging supplies provided: [Items and quantities]. Competency/safety issues: [Any caregiver concerns and instructions provided]

Handoff and Continuity

Receiving clinician/facility/hospice: [Name, role, organization, contact]

Verbal handoff: [Who spoke with whom, date/time, key points conveyed]

Records sent: [Discharge summary / Plan of care / Orders / Advance directives/POLST / Medication list / Other]. Method: [Fax / Secure email / EHR exchange / Paper]. Confirmation: [Confirmed received / Pending: follow-up plan]

Patient/family communication: [Who was informed, their understanding, questions or concerns raised]

(If no receiving entity) PCP notification: [Notified: date/method / Attempts made: details]. Instructions given to patient: [How to access care and follow-up]

Follow-up Instructions

Appointments: [Scheduled appointments or timeframe to schedule]

Ongoing management: Prescriber for refills: [Name/contact]. DME management: [Name/contact]. Urgent issues: [Who to call]. ED criteria: [When to go to ED]

Red-flag symptoms: [Symptoms requiring immediate attention]

Code status and advance directives: [Current status and portability instructions]

Gap in services safety plan: [Plan if gap anticipated, otherwise "No gap anticipated"]

Instruction delivery method: [Paper / Portal / Verbal with teach-back]

Pending Items

• [Pending test] – Expected: [Date] – Follow-up owner: [Name/role]
• [Pending referral/authorization] – Status: [Details] – Owner: [Name/role]
• [Unresolved clinical issue] – Reassess by: [Timeframe] – Owner: [Name/role]

(If none, state: "No pending tests or outstanding tasks at time of discharge.")

Signature

Author: [Name, credentials] | Date/time signed: [MM/DD/YYYY HH:MM] | Role: [Title]

Co-signatures: [Names, credentials, date/time] (If required per organizational policy)

Addendum plan: [Pending item] – Required by: [MM/DD/YYYY] – Owner: [Name/role] (Include only if critical items remain pending at time of signing)