Hospice Face-to-Face Encounter Note for Recertification

Patient: [name, DOB, MRN]

Hospice: [agency name]

Encounter Date: [date of face-to-face]

Setting: [home / SNF / ALF / inpatient unit / other]

Modality: [in-person / telehealth] (If telehealth, specify patient and practitioner locations.)

Benefit Period: [number, e.g., "3rd" or "5th"] [start date – end date if available]

Practitioner: [name, credentials, role]

Historian: [patient / caregiver name and relationship / facility staff] (Note reliability limitations if applicable.)

Reason for Encounter

[Two to three sentences: state this is a face-to-face encounter for hospice recertification for the upcoming benefit period, identify the terminal diagnosis with key related conditions, and note current level of care if relevant.]

Interval History / Clinical Trajectory

[Summary of timeframe since last certification and overall trajectory: stable / fluctuating / declining. Include significant events such as hospitalizations, infections, falls, new symptoms, or medication changes. Clearly distinguish reported history from record review.]

• Functional status: [PPS or plain-language description with comparison to prior; include dates if known]
• ADL dependence: [level of assistance required and changes since prior period]
• Nutrition/weight: [intake pattern, weight trend with dates; if unavailable, note reason or alternative observations such as visible wasting]
• Cognition/alertness: [orientation, attention, meaningful interaction, changes]
• Cardiorespiratory: [dyspnea, oxygen requirements, edema, work of breathing]
• Skin integrity: [pressure injuries or wounds with stage/location if present]
• Symptom burden: [pain control, other prominent symptoms, medication adjustments]

Objective (F2F Findings)

(Document findings personally observed during this encounter.)

• Vitals: [BP, HR, RR, Temp, SpO2 as obtained] (If not obtained, state reason.)
• General: [appearance, distress level, cachexia, ability to engage]
• Mental status: [alertness, orientation, ability to follow commands]
• Cardiorespiratory: [respiratory effort, accessory muscle use, edema, perfusion]
• Nutritional markers: [temporal wasting, clavicular wasting, visible weight loss]
• Mobility: [bed/chair/ambulatory status, transfer ability observed]
• Skin: [pressure injuries with stage/location if present; wound status]
• Functional scale: PPS [percent]% (Support with specific abilities and limitations observed.)

Assessment / Prognostic Narrative

[Terminal diagnosis] with contributing conditions: [key comorbidities and complications].

[Patient-specific narrative linking disease burden, documented decline since prior certification, and today's findings to limited life expectancy. Cite specific comparisons, dates, and objective anchors. Avoid generic phrases without supporting detail.]

Prognosis: Based on the above findings, the patient's prognosis is six months or less if the illness runs its normal course. (If authored by hospice NP or non-certifying physician, add: These clinical findings have been provided to the certifying physician.)

Plan

• Symptom management: [active domains: pain, dyspnea, agitation, GI, wounds; current approach and any changes]
• Goals of care: [confirmed or updated; code status]
• [Continue current hospice plan of care / Update hospice plan of care as above]

Face-to-Face Encounter Attestation

[I personally performed a face-to-face encounter with this hospice patient on [Encounter Date] for hospice recertification and to gather clinical findings supporting continued eligibility.] (For hospice NP or non-certifying physician, use instead: I personally performed a face-to-face encounter with this hospice patient on [Encounter Date] for hospice recertification. The clinical findings from this encounter have been provided to the certifying hospice physician for use in determining continued hospice eligibility.)

Signature: [electronic signature]

Printed Name/Credentials: [name, MD/DO/NP]

Date Signed: [date]

(Compliance notes: Do not omit encounter date, practitioner identity, attestation language, signature, or date signed. The prognostic narrative must include patient-specific findings supporting a prognosis of six months or less.)