Inpatient Respite Care Admission/Progress Note

Note Type: [Respite Admission / Respite Progress]

Date/Time: [Date and time]

Author: [Name, credentials]

Patient: [Full name] [Identifier]

Location: [Facility], [Unit/Room]

Attending/Hospice Medical Director: [Name]

Respite Timeline: [Admit date]; [Planned discharge date]; [Current respite day, e.g., Day 2 of 5]

Primary Caregiver: [Name], [Relationship], [Contact number]

(Complete all header fields. If any item is unknown, document what is known and create a plan item to obtain the missing information.)

Reason for Respite Stay

[Caregiver relief indication and source of information]

(Required on every note. Do not infer caregiver inability; attribute to caregiver report, staff observation, or collateral. For Admission: Clearly link respite to caregiver need, e.g., "Admitted for inpatient respite to provide caregiver relief for [relationship] due to [reason]." Include whether the caregiver expects to resume care at discharge, who requested respite, and requested duration. Document patient assent; if lacking capacity, identify the surrogate decision-maker. For Progress: State whether the respite indication remains unchanged and update caregiver readiness for discharge.)

Patient Baseline

[Patient baseline summary]

(For Admission: Provide a concise snapshot including terminal diagnosis context, baseline residence and caregiving arrangement, baseline cognition and historian, functional status, baseline symptom burden and what constitutes "stable" for this patient, diet and medication route, and key supports/equipment. If baseline is incomplete, state what is known and add reconciliation to the plan. For Progress: State "Baseline unchanged" only if explicitly assessed; otherwise document trends away from baseline such as decline, delirium, or reduced intake.)

Clinical Course

[History of present illness or interval history]

• [Targeted detail, if needed]

(For Admission—HPI format: Frame as respite admission with current symptom stability. Cover symptom status since prior setting including pain, dyspnea, nausea, agitation, constipation, secretions, sleep. Include recent events such as falls, infections, ED visits, medication changes, or missed doses. Note last bowel movement and intake/hydration if relevant. For Progress—Interval history: Summarize overnight events, nursing concerns, PRN use with response and adverse effects, intake highlights, and new symptoms or red flags. Organize by symptom domain as bullets when helpful.)

Current Symptoms

(Address only domains relevant to this patient. When the patient cannot self-report, document observable signs and identify the reporter. Omit domains that do not apply.)

• Pain: [Location, severity, triggers, relief]
• Dyspnea: [Severity, oxygen settings, relief measures]
• Nausea/Appetite: [Symptoms, intake tolerance]
• Bowel Function: [Pattern, last BM, interventions]
• Anxiety/Agitation: [Symptoms, precipitating factors]
• Sleep: [Quality, disturbances]
• Skin Comfort: [Pressure areas, wounds, pruritus]

Medications

Allergies: [Allergies / NKDA (verified)]

(For Admission: Document sources used for reconciliation. Group current medications as scheduled and PRN; flag high-risk medications for monitoring. State whether home regimen is continued unchanged or list additions, holds, or discontinuations with rationale. Note facility formulary constraints and mitigation. If controlled substances arrived with the patient, document count verification and storage. If the list is incomplete, state what is missing and include reconciliation in the plan.)

• Reconciliation sources: [Caregiver list / prior MAR / pharmacy records / hospice chart]
• Scheduled: [Name, dose, route, frequency]
• PRN: [Name, dose, route, frequency, indication]
• High-risk medications flagged for monitoring: [List]
• Changes from home regimen: [Additions / Holds / Discontinuations with rationale]
• Formulary issues and mitigation: [Details, if applicable]
• Controlled substances: [Count verification, storage]
• Reconciliation status: [Complete / Incomplete—missing items and plan to obtain]

(For Progress: Document medication changes made today with dose, route, frequency, and rationale. State "Medications unchanged" only if no modifications were made.)

Goals of Care

• Code status: [Status]; [Location of documentation: POLST / advance directive / hospice consent]
• Surrogate decision-maker: [Name, relationship, contact]
• Goals for respite interval: [Symptom targets, caregiver relief goals]
• Escalation preferences: [Hospitalization / antibiotics / IV fluids / other preferences discussed]

(For Progress: State "Reviewed, unchanged" if confirmed, or document updates. If code status is unknown, document as requiring urgent clarification and include an interim safety plan.)

Physical Examination

• Vitals: [Values / not obtained per symptom-driven protocol]
• General/Mental status: [Appearance, alertness, orientation, comfort level]
• Respiratory: [Effort, breath sounds, secretions, oxygen delivery]
• Cardiovascular/Edema: [Rate, rhythm if assessed, peripheral edema]
• Abdomen: [Softness, tenderness, bowel sounds, distension]
• Skin: [Integrity, pressure areas, wounds]
• Devices: [Foley, feeding tube, drains—status and function]
• Pertinent results this stay: [Labs or imaging if performed]

(Prioritize symptom-relevant findings over exhaustive normal documentation.)

Assessment

[Clinical stability statement and symptom control status] [Comparison to baseline: stable / improving / declining, with supporting evidence] [Active problems requiring management during respite]

(If deterioration is present, explicitly address need for increased monitoring or change in level of care.)

Plan

(Organize by problem in priority order. For each, include current status or goal, interventions, monitoring parameters, and escalation triggers.)

[Problem 1]

• Status/Goal: [Current status and target]
• Interventions: [Pharmacologic and non-pharmacologic measures]
• Monitoring: [Parameters and thresholds]
• Escalation triggers: [Signs prompting provider notification]

[Problem 2]

• Status/Goal: [Current status and target]
• Interventions: [Details]
• Monitoring: [Details]
• Escalation triggers: [Details]

Caregiver Relief and Discharge Planning

• Planned discharge: [Date], [Destination: home / other setting]
• Receiving caregiver: [Name, relationship, contact]
• Medications and supplies needed: [List and readiness status]
• Follow-up plans: [Next home visit timing, after-hours contact]
• Transportation: [Arrangements and responsible party]
• Caregiver readiness: [Ready / Not ready—barriers and alternatives being explored]
• Outstanding tasks: [Items to complete prior to discharge]

Care Coordination

• [Communication entry: Spoke with Name/Role on Date regarding Topic; Outcome/Next step]
• [Additional communication entries as needed]

(Document explicit agreement or concerns; do not imply agreement without confirmation.)

Signature

[Electronic signature, credentials]

[Co-signature, if required by policy]