Hospice Evaluation and Referral Note

Date/Time: [Encounter date and time]

Setting: [hospital / clinic / SNF / home / telehealth]

Author/Service: [Author name, credentials, and consulting service]

Reason for Consult: [Reason for hospice evaluation or transition]

Participants: [Patient; family/surrogate with relationship and legal basis if applicable; interpreter if used; care team members present]

Note Type: [Evaluation only (no referral) / Informational visit requested / Hospice referral placed / Urgent hospice transition]

Clinical Summary

[Brief narrative synthesis of primary terminal diagnosis with current stage/trajectory, recent major events driving hospice consideration, current symptom burden and functional status, and why hospice is being considered now] (3–6 sentences. Include time anchors for trajectory statements. Avoid generic language; tailor to this encounter.)

Hospice Eligibility Assessment

Terminal Diagnosis: [Primary life-limiting condition; related conditions contributing to trajectory; key comorbidities affecting prognosis]

Decline Trajectory: [Objective markers of decline with dates—functional changes, nutritional decline/weight loss, recurrent hospitalizations, treatment limitations or disease progression despite therapy] (Use time anchors. If data unavailable, document why.)

Performance Status: [PPS / ECOG / FAST / NYHA / disease-specific staging and score] (Omit if not assessed.)

Prognosis Statement: [Explicit clinician judgment in direct language, e.g., "I believe prognosis is likely weeks to a few months based on..."] (Required. If uncertain, state uncertainty and re-evaluation plan. If patient is not hospice appropriate, document which criterion is not met, alternative pathway, and triggers for re-evaluation.)

Goals-of-Care Discussion

Capacity/Surrogate: [Capacity adequate / capacity impaired; if impaired, name surrogate, relationship, and legal basis] (If not assessed, state reason.)

Illness Understanding: [Patient/family understanding of illness and expected course]

Prognosis Communication: [Who was present; what was discussed; key reactions and supports provided] (Use brief direct quotes only for high-salience preferences.)

Goals and Values: [What matters most; desired location of care; acceptable tradeoffs; major fears/concerns]

Treatment Preferences: [Hospitalization preference; code status and whether changed today; POLST/MOLST status; other relevant boundaries if discussed]

(If goals-of-care or prognosis not discussed this encounter, state "Not discussed today" and reason.)

Assessment

[Synthesis of hospice appropriateness: appropriate / likely appropriate / not appropriate now; primary drivers including prognosis, symptom burden, functional decline, and goal alignment; barriers or constraints if present]

Plan

Level of Care/Setting: [Recommended hospice level: routine home / continuous home care / general inpatient / inpatient respite] (Include rationale, planned discharge location, and safety considerations.)

Symptom Priorities: [Immediate symptoms of concern; proposed approach including medication classes and routes; what to continue until hospice intake; contingency plan for symptom escalation prior to admission]

Transition Logistics: [DME needs and timing; caregiver availability and education needs; hospice agency selected and contact status; referral placed yes/no with date; who manages symptom escalation until hospice admission begins]

(If hospice declined or deferred: document reasons, education provided, alternative plan, and re-evaluation triggers.)

(For unavailable information, state reason. For high-importance gaps such as missing surrogate contact, referral status, or disposition timing, note who will obtain the information.)