Symptom Crisis Visit Note (Hospice PRN/After-Hours)

Patient: [name, DOB/MRN]

Encounter Type: [PRN / after-hours / on-call crisis visit]

Location: [home / ALF / SNF / other]

Call Received: [time]

Arrival: [time]

Visit End: [time]

Clinician: [name, credentials]

Others Present: [caregiver names, facility staff, interpreter if applicable]

Trigger

[Crisis summary: primary symptom(s), acuity markers, who called, immediate safety context] (One to three sentences; include direct quotes only if they convey severity or urgency.)

Subjective

[Focused crisis narrative combining baseline context and HPI: hospice diagnosis and relevant comorbidities; baseline symptom control; onset, severity, character, aggravating/relieving factors; interventions tried and response; patient/caregiver goals for this episode; medication adherence issues; pre-arrival triage summary if applicable] (Keep concise and strictly crisis-focused.)

Objective

Appearance/Safety: [general distress level, consciousness, immediate ABC or environmental safety concerns]

Vitals/Scores: [relevant vitals, pain score, dyspnea rating, sedation level as applicable] (If not obtained, state reason.)

Focused Exam: [pertinent positives and negatives related to presenting crisis only]

Medications: [current symptom meds scheduled and PRN; last doses/times; route feasibility; comfort kit availability]

Environment/Caregiver: [caregiver present, distress level, competence; home safety or DME issues; plan feasibility]

Assessment

1. [Crisis problem in order of urgency]: [severity with supporting evidence] – [most likely cause] – [reversible contributors considered]
2. (Include additional problems as applicable; list in order of urgency.)

Interventions & Response

• [Time] – [action/medication/dose/route] – [indication] – [immediate observation]
• [Time] – [reassessment: updated symptom ratings, observable signs, adverse effects, progress toward goals]
• [Time] – [intervention considered but not done] – [reason]

(Enter chronologically; repeat entries as needed until stabilized or disposition determined.)

Plan

Orders Obtained: [ordering clinician] – [mode: phone / secure message] – [time] – [order details] – [read-back confirmed: yes / no] – [new order / clarification / comfort-kit protocol]

Medication Changes: [prior regimen] → [new regimen] – [indication, PRN frequency limits, safety parameters]

Escalation Decision: [remain routine / initiate CHC / recommend GIP-IPU / ED-EMS] – [rationale] (If CHC: document start time and why continuous nursing required. If GIP: note precipitating event and why home management failed. If ED/EMS: document rationale and code status/POLST.)

Caregiver Education: [topics taught] – [teach-back result: successful demonstration or verbalization / requires reinforcement]

Follow-Up: [next contact and timeframe] – [contingency if symptoms recur] – [medication/equipment delivery plan] – [patient condition at departure]

Signature: [clinician name, credentials, date/time]