Fundamentals of Effective Hospice Documentation

1. Introduction to Effective Documentation

The clinical record is considered the most reliable account of care, yet clinicians seldom have their contributions to health care recognized, in part due to inadequate documentation. This chapter reviews the importance of accurate and complete documentation to the health care community, the organization, and the clinician specifically.

2. Documenting Eligibility for Interdisciplinary Team Members

Terminal diagnoses are dynamic in hospice, meaning they can and do change over time. This chapter reviews common diagnoses, Medicare’s view of the terminal diagnosis, the use of eligibility guidelines in complete and accurate documentation, and the use of standardized and evidence-based tools.

3. Telling the Story

Team members accomplish a lot in a brief visit. Does the documentation support all of the efforts, actions, and results of care? This chapter reviews the significance of telling the complete story of the patient and the visit.

4. Situational Documentation

Transitions of care, higher levels of care, discharges, revocations, and other changes are critical times in patient care and safety. This chapter reviews these specific situations and the documentation requirements and recommendations surrounding these risk areas.