Hospice Admission Note Template

What is a hospice admission note?

A hospice admissions document or hospice admission note is a comprehensive form used when a patient is admitted into a hospice organization. It serves as a foundational record that outlines essential information, establishes care preferences, and initiates the provision of end-of-life care services.

Hospice admissions documentation includes the patient's medical history, health status, and care preferences during their final phase of life. Essential patient information, such as their medical background, diagnoses, ongoing treatments, medications, and prior hospitalizations or surgeries, is also recorded.

The admissions document outlines hospice patients' goals and wishes concerning their end-of-life care. This includes preferences for pain management, symptom control, spiritual or emotional support, and their choices regarding life-sustaining treatments like resuscitation or artificial nutrition. This section ensures optimal patient care that aligns with the patient's values, beliefs, and desires.

Thorough documentation is a cornerstone for initiating personalized, compassionate, patient-centered care. It ensures that care providers comprehensively understand the patient's medical condition, personal preferences, and care goals, facilitating the delivery of supportive and comforting end-of-life care tailored to the individual's needs and wishes.

Components of hospice admission documentation

This Hospice Admissions Note template is designed to gather essential components of hospice documentation, establish care preferences, and initiate end-of-life care services for patients. These typically include:

• Patient information: Demographic details such as the patient's name, address, contact information, date of birth, and identification numbers.
• Medical history: information about the patient's medical background, including diagnoses, ongoing treatments, surgeries, hospitalizations, and current medications.
• Primary care physician details: Contact information and collaboration details for the patient's primary care physician or referring healthcare provider.
• End-of-life care preferences: the patient's directives regarding end-of-life care, including pain management, symptom management, resuscitation preferences, spiritual or emotional support, and desired interventions.
• Consent and acknowledgment: Confirmation of the patient's consent to hospice care, understanding of services provided, rights and responsibilities, insurance coverage or financial considerations, and acknowledgment of the hospice program's policies and procedures.
• Goals and expectations: Collaboratively established goals and expectations for hospice patient care, as well as the patient's needs and desired outcomes during their end-of-life journey.
• Documentation of assessments: Initial assessments are conducted by a hospice care team member (typically a hospice nurse during a hospice admission visit). They detail the patient's physical, emotional, social, and spiritual needs.
• Legal and regulatory documents: Legal documents, such as advance directives, healthcare power of attorney, living wills, or other legal forms pertinent to end-of-life care and decision-making, may be attached to the admission note.

How does the Hospice Admission Note Template work?

The admissions process for hospice care can be lengthy. The Hospice Admission Note Template is a valuable resource for streamlining hospice documentation and ensuring all aspects of care can be met by the facility. Here are some hospice documentation tips for creating a viable admissions note:

Step 1: Prepare

Make sure that you have a copy of the free hospice admission note PDF by following the link on this page. You can select "Use template" to open and customize this template within the Carepatron platform or click "Download" to get a fillable PDF copy. This template can be printed or filled digitally.

Step 2: Record patient information

Begin by collecting basic information about the patient, such as their primary physician, medical history, and hospice eligibility. Utilize resources such as end-of-life admission guidelines and healthcare facility checklists to ensure the document meets all regulatory requirements.

Step 3: Medical assessment

Include items related to the patient's medical needs and comfort and a comprehensive nurse admission narrative. Ensure the patient's condition at admission is thoroughly recorded to document decline or improvement.

Step 4: Personal care needs

Input information about the patient's care needs and preferences. Document the patient's requirements for daily living assistance, such as bathing, dressing, mobility assistance, dietary needs, and any specific care instructions.

If you need a checklist to remind you of the documentation process, download our Cheat Sheet Hospice Documentation Template.

Benefits of using a Hospice Admission Note Template

Utilizing a hospice documentation template streamlines the admission process and allows hospice nurses to follow established standards for the best possible care.

Here are some of the benefits of using this template:

Standardized information gathering

An admissions template provides a structured format for systematically collecting all necessary information about the patient's medical history, current health status, and preferences for end-of-life care. This template ensures critical details are not overlooked, and high documentation standards are met from admission to hospice charting.

Efficiency and time-saving

This template is designed to streamline admissions, allowing healthcare professionals to gather key information efficiently. This saves time and enables quick access to essential details relevant to a patient's condition or care plan.

Consistency in documentation

Consistent hospice nurse documentation aids in the continuity of care, allowing multiple care providers within the hospice team to access standardized and organized information about the patient.

Facilitating communication and collaboration

Comprehensive documentation practices within a hospice setting promote effective communication among healthcare professionals, patients, and their families. The hospice admission note facilitates interdisciplinary collaboration and clear communication by providing a standardized format, ensuring all parties are on the same page regarding the patient's condition, preferences, and care plan.

Enhancing quality care

Accurate and comprehensive documentation through an admissions template supports informed decision-making, personalized care planning, and patient-centered care. It ensures that the care provided aligns with the patient's wishes, improving the quality of their end-of-life experience.