Hospice Interdisciplinary Visit Note (Routine Home Care)

Date/Time of Service: [start and end time]

Visit Setting: [private home / assisted living / group home / other community setting]

Discipline: [RN / LPN/LVN / NP / MD / SW / Chaplain / other]

Clinician: [name, credentials]

Patient Present: [Yes / No] (If no, state reason.)

Caregiver(s) Present: [name(s) and relationship(s), or none]

Others Present: [family, facility staff, interpreter, or none]

Hospice Diagnosis: [principal diagnosis and key related conditions]

Level of Care: Routine Home Care

Visit Reason: [routine skilled assessment / symptom follow-up / medication or DME issue / caregiver support or teaching / psychosocial or spiritual support / care-plan coordination / other]

Visit Summary

[1–4 sentence snapshot including trajectory statement, highest-burden symptoms with change since last contact, and key action taken] (Trajectory options: declining / stable / waxing-waning / actively dying suspected. Tie trajectory to concrete observations.)

Subjective

Information Source(s): [patient report / caregiver report / chart review / direct observation] (If patient cannot report, state reason and specify alternative sources.)

Interval History: [symptom changes with timeline; sleep; appetite and intake; bowel pattern; cognition or behavior changes; falls or safety events; care transitions or ED discussions]

Medication Experience: [what was actually taken; effectiveness; adverse effects; barriers to adherence]

Caregiver Assessment: [understanding; confidence; distress level; respite needs; safety concerns]

Goals of Care / Advance Directives: [newly discussed or changed preferences] (Include only if newly discussed or changed; otherwise omit this field.)

Objective

General: [level of alertness; distress; work of breathing; comfort at rest; hydration cues]

Vitals: [relevant vital signs if obtained, or rationale if not obtained] (Include only if needed for symptom management, medication safety, oxygen titration, or deterioration assessment.)

Exam: [focused findings relevant to current issues by system] (Document only systems assessed.)

Function/Safety: [functional status score if used; mobility and transfer safety; ADL changes; home environment concerns]

Symptom Assessment

Pain: [presence; severity with scale used; character and location if present; analgesic effectiveness; side effects] (For nonverbal patients, specify observational tool and describe observed behaviors.)

Dyspnea: [presence at rest or exertion; impact on function and sleep; treatments used and response]

Other Symptoms: [other clinically relevant symptoms assessed with brief status] (Include only symptoms assessed or actively managed.)

Impact Rating: [mild / moderate / severe for each key symptom] (If any symptom is moderate or severe, document follow-up plan within 2 calendar days.)

Assessment

Overall Trajectory: [improving / stable / declining / imminent death suspected] (Tie to observed findings. If imminent death suspected, document objective signs and family education provided.)

[Problem 1]

[Status, supporting evidence, contributing factors, and immediate risks]

[Problem 2]

[Status, supporting evidence, contributing factors, and immediate risks]

(Order problems by severity and urgency. Include symptom priorities, functional decline, caregiver capacity, and barriers to plan. If home management not feasible, state rationale for level-of-care change.)

Plan

[Problem 1]

• Interventions today: [pharmacologic and nonpharmacologic actions performed]
• Medication changes: [changes requested or ordered and by whom]
• Contingency instructions: [call parameters given to patient and caregiver]
• Follow-up: [timing and responsible discipline]

[Problem 2]

• [Repeat structure for additional problems as needed]

Education

[Topics covered; recipient(s); method; comprehension evidence] (Required documentation. Topics may include symptom management, medication administration, DME use, oxygen safety, controlled substance safe use and storage and disposal, what to expect, caregiver self-care.)

Medication/DME Status

Medication reconciliation: [confirmed / discrepancies identified / changes made]

Controlled substances: [education provided and caregiver understanding, or not indicated]

DME/Supplies: [equipment function; training provided; supply adequacy; escalation if needed]

Coordination

[IDG updates; physician or NP notifications and orders; non-hospice provider coordination; referrals initiated]

Next Visit

[Routine next visit date and discipline] (If any symptom impact is moderate or severe, document follow-up within 2 calendar days or state barriers.)

Domain Coverage: [psychosocial and spiritual domains addressed or deferred with follow-up plan]

Clinician Signature: [electronic signature]

Date/Time Signed: [date and time]

Co-signature: [name and credentials if required by policy]