Hospice maintains a comprehensive and accurate record of services provided in all care settings for each patient and family.
Documentation in the hospice services record is descriptive, accurate, and includes:
• Physical condition of the patient, including a current history and physical
• Psychosocial status of patient and family
• Spiritual status of the patient and family
• Potential bereavement complications
• Care provided from admission through bereavement
• Patient and family response to services provided
• Interdisciplinary team plan of care
• Physician’s signed orders for care
• Identification of a primary caregiver and/or person to contact in an emergency
• Signed informed consent and evidence that the patient has received a statement of their rights and responsibilities
• Documentation addressing patient resuscitation status
• Signed copies of any advance directives