Hospice Medication Management Note (Comfort Kit/Deprescribing)

Date/Time: [Encounter date and time]

Author: [Name, credentials, role]

Encounter Type: [in-person home visit / facility visit / phone / video]

Location: [home / ALF / SNF / inpatient hospice; facility name if applicable]

Participants: [Patient, caregivers, facility staff present]

Reason for Encounter: [admission med rec / symptom change / comfort kit initiation / deprescribing review / other]

Hospice Context and Goals

[Primary hospice diagnosis, relevant comorbidities, and clinical factors affecting medication decisions such as swallowing ability, renal/hepatic function, cognition, or symptom burden] (If specific factors were not assessed, state that explicitly.)

[Current care goals in patient or family words] (If goals were not discussed today, state that changes follow the existing hospice plan of care.)

Allergies: [Allergies and adverse reactions with reaction types if known; NKDA if applicable]

Medication Reconciliation

Sources used: [med bottles / facility MAR / pharmacy profile / discharge summary / caregiver report] (Note any reliability concerns or missing information.)

Reconciled Medication List: [Complete list of prescriptions, OTC, supplements, and topicals with name, dose, route, frequency, indication, and actual use if different from prescribed]

Discrepancies / Duplications / Interactions / High-risk flags: [Identified issues and resolution or plan] (If none found, state "No discrepancies identified.")

Medication Changes and Comfort Plan

Medication changes made this encounter: (For each change, include medication name, action, and rationale. Acceptable rationales include: time-to-benefit exceeds prognosis, burden exceeds benefit, adverse effect risk, pill burden, duplication, monitoring burden. For tapers, include schedule and withdrawal symptoms reviewed.)

[Medication changes with rationale for each]

Comfort kit: (Include only if kit was ordered, reviewed, or taught this encounter. If kit is present but not addressed, state "Comfort kit present; not reviewed this encounter.")

• Kit contents: [Medications with PRN indications and dose ranges]
• Caregiver education: [Who received teaching; topics covered; teach-back results]
• Storage and access: [Storage location; after-hours access plan]

Opioid bowel regimen: (Include if opioids are part of the plan.)

[Prophylactic agents; escalation steps if no BM within specified timeframe; red flags reviewed with caregiver]

Controlled Substance Documentation

(Required whenever controlled medications are newly ordered for home use.)

• [Controlled medications ordered with names, strengths, quantities]
• [Hospice controlled substance policies provided and discussed in understandable language; education recipient documented]
• [Safe storage and diversion prevention counseling provided]
• [Disposal if occurred: drug name, strength, quantity, date/time, method, witness if required by policy]

Coordination and Follow-up

Notifications: [Pharmacy, prescriber, and facility communications with who, when, how, and confirmation received]

Follow-up plan: [Timing of reassessment; triggers for urgent contact; responsible team member]

Signature: [Author name, credentials, role, contact]