Hospice Plan of Care (Interdisciplinary)

Document Title: Hospice Plan of Care (Interdisciplinary)

Patient: [Name], [DOB], [MRN]

POC Status: [Initial / Routine Update / Change in Condition / Post-Hospitalization / Setting Change]

Effective Date: [date]  |  Review Due Date: [date]

Care Setting: [Home / ALF / SNF/NF / Inpatient Hospice / Hospital GIP]

Level of Care: [Routine Home Care / Continuous Home Care / Inpatient Respite / General Inpatient]

Attending Clinician(s): [names and credentials]

Primary Caregiver: [name and relationship]  |  Interpreter Needs: [None / language and modality]

Interdisciplinary Team Participants

(Document all IDG members present or consulted. Identify RN case manager explicitly. If any role is unfilled, note "Pending assignment by [date].")

Name	Discipline/Role	Participation	RN Case Manager	Attending Involvement	Notes
[Name]	[RN / MD / NP / PA / SW / Chaplain / HHA / PT / OT / SLP / Volunteer / Other]	[Present at IDG / Consulted outside meeting]	[Yes / No]	[Present / Contacted, orders received / Contacted, no new orders / Not reached]	[notes or pending status]

Clinical Context

[Terminal diagnosis, key related conditions driving hospice needs, current functional trajectory, and top active symptoms with severity. Include recent events affecting the plan and any safety or caregiver capacity constraints.] (2–4 sentences; may abbreviate on minor updates if changes are conveyed in the problem list.)

Patient and Family Goals of Care

• Overall Goals: [Patient-centered statement: comfort priority, alertness preferences, hospitalization avoidance, preferred location of care and death]
• Decision-Maker: [Patient capacity status]; Legal Surrogate/Representative: [name and role, or N/A]
• Code Status: [Full Code / DNR / DNI / Other]; Documents: [DNR / POLST / MOLST / None]; Location: [where stored] (If not yet clarified, state: "Not yet clarified; discussion planned by [discipline] on/by [date].")
• Cultural, Spiritual, or Communication Preferences: [details impacting care delivery]

Active Problem List and Care Plan

(Organize by problem, not by discipline. Number by priority. Link medications to problems. Include education with teach-back when part of intervention. If a service is declined, retain the problem and document declination with reason. Problems without actionable interventions belong in Clinical Context.)

Problem #1: [Problem name – patient-specific statement]

Status: [New / Active / Improving / Worsening]  |  Priority: [High / Medium / Low]

Assessment Summary: [Brief supporting facts: severity scores, triggers, objective findings justifying the plan]

Goals/Outcomes: [Baseline → measurable target within timeframe] (e.g., "Pain ≤3/10 at rest within 72 hours")

Interventions by Discipline:

• RN: [Intervention]; Frequency: [schedule]; Parameters: [escalation triggers or PRN criteria]; Education/Teach-back: [topic and competency status]
• MD/NP/PA: [Orders/interventions]; Follow-up: [timeline]; Medications linked: [name, dose, frequency, PRN parameters]
• SW: [Psychosocial/resource interventions]; Frequency: [schedule]; Escalation: [criteria]
• Chaplain: [Spiritual care interventions, or declined]; Frequency: [schedule]
• HHA: [Personal care tasks]; Frequency: [schedule]; Safety focus: [fall/skin precautions]
• Therapies (PT/OT/SLP): [Goals and interventions, if applicable]; Frequency: [schedule]
• Non-Pharmacologic: [Positioning, oxygen, fan therapy, relaxation techniques linked to this problem]

Progress (on updates): [Progress toward outcomes since last plan; changes if goals not met]

(Repeat problem blocks as needed, ordered by priority.)

Medication and Treatment Plan

Reconciliation Status: [Completed / Pending]; Data Sources: [patient/caregiver report, pharmacy records, EHR, facility MAR, other]

Medication	Indication (Problem #)	Dose	Route	Frequency	PRN Parameters	Prescriber	Coverage
[Medication name]	[Problem # and indication]	[dose]	[route]	[frequency]	[trigger criteria]	[name, credentials]	[Hospice-covered / Unrelated]

Symptom/Comfort Kit: (List anticipatory medications with explicit indications and triggers.)

• [Medication] – [Indication]; [Trigger/PRN parameters]; [Dose/route]

• Safety Monitoring: [Sedation/respiratory monitoring for opioids/benzodiazepines; bowel regimen with opioids; fall precautions with CNS-active medications]
• Controlled Substance Education: [Safe use, storage, and disposal education provided; location of written guidance]
• Non-Pharmacologic Treatments: [Oxygen, positioning, fan therapy, relaxation techniques with problem linkage]

(If orders are pending, state intended strategy and "Order pending; expected by [date/time].")

Supplies and DME

(If none required, state "None required at this time.")

Item	Indication (Problem #)	Delivery Status	Training Provided	Competency Demonstrated	Notes
[Item]	[Problem # / indication]	[Ordered / Delivered / Pending]	[Training topic and date]	[Yes / Needs reinforcement]	[Maintenance or vendor info if relevant]

Visit Frequencies by Discipline

(Frequency ranges must not include zero. If PRN visits are used repeatedly, update scheduled frequency.)

Discipline	Frequency	Visit Goals	PRN Triggers
[RN / HHA / SW / Chaplain / Physician/NP/PA / PT / OT / SLP / Volunteer]	[e.g., 2x/week or 1–2x/week]	[What this frequency accomplishes]	[Symptom crisis / caregiver distress / imminent phase / other]

Education and Training Plan

• Medication Administration: [Topics covered]; Competency: [Demonstrated / Needs reinforcement]; Plan: [follow-up]
• DME Use and Safety: [Topics: oxygen, hospital bed, etc.]; Competency: [status]; Plan: [reinforcement needs]
• Symptom Recognition and When to Call: [Red flags and contact process]; Competency: [status]
• Skin Care and Safe Transfers: [Topics]; Competency: [status]
• Imminent Death Education: [Topics, if appropriate]; Understanding: [status]
• Caregiver Availability: [If unavailable, document attempts, alternative plan, and interim risk mitigations]

Coordination and Contingency Planning

• Hospice Contact: [Primary contact]; [After-hours process]
• Clinician Communication: [Plan for coordinating with attending physician and other treating clinicians]
• Facility Coordination: [If in SNF/ALF: facility contact, role delineation, crisis communication chain] (Omit if home setting.)
• Crisis Escalation: [Stepwise plan for symptom crisis; criteria for level-of-care change consideration]
• Hospitalization Avoidance: [Plan to manage symptoms to avoid transfer; communication responsibilities if transfer occurs]

Psychosocial, Spiritual, and Caregiver Plan

• Psychosocial Stressors and Safety Concerns: [Details]; SW Interventions: [planned actions/resources]
• Spiritual/Existential Assessment: [Findings]; Chaplain Supports: [offered / accepted / declined]
• Cultural Practices to Honor: [Details]
• Caregiver Strain/Bereavement Risk: [Low / Moderate / High]; Planned Supports: [interventions/referrals]

Patient/Representative Understanding and Agreement

• Participants in Plan Discussion: [Patient, representative, and/or caregiver names and roles]
• Evidence of Understanding: [Teach-back summary or key points confirmed]
• Agreement Statement: [Patient/representative agrees with plan as outlined / Specific declinations with reason]
• Disagreements: [Disputed element and resolution plan, if any; otherwise state "None"]

Plan Revision Log

Review Date	Participants	Reason for Update	What Changed	Progress Toward Outcomes	Next Review Due
[date]	[names/roles]	[Routine 15-day review / Change in condition / Other]	[Problems, goals, medications, frequencies updated]	[Met / Partially met / Not met]	[date]

Authentication

Author: [name, credentials]  |  Date/Time Completed: [date/time]

IDG Approval Attestation: [Names, credentials, date/time of approving IDG members per organizational policy]

Physician/Attending Acknowledgment: [Name, credentials, date/time] — "I have reviewed and approve this interdisciplinary plan of care."