Hospice Admission Note Template

What is a hospice admission note?

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

This document encompasses multifaceted details about the patient’s medical history, current health status, and preferences for care during their final phase of life. It includes personal information such as the patient’s name, address, contact details, and demographic data. Additionally, it delves into the patient’s medical background, detailing diagnoses, ongoing treatments, medications, and any prior hospitalizations or surgeries.

The admissions document outlines the patient’s goals and wishes concerning their end-of-life care. This section encompasses the patient’s 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 that care aligns with the patient’s values, beliefs, and desires, promoting a dignified and comfortable end-of-life experience.

Moreover, the admissions document involves the patient’s acknowledgment and consent to hospice care, detailing the services provided by the hospice team, the rights and responsibilities of the patient and their family, and any financial considerations or insurance coverage related to hospice care.

Completing this document typically involves collaboration between the patient, their family members or designated healthcare proxies, and the hospice team, including nurses, social workers, and medical professionals. The process may entail discussions, explanations, and decision-making regarding the goals and expectations of hospice care.

The admissions document is a cornerstone for initiating personalized, compassionate, patient-centered care in hospice. 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 document

Hospice admissions document comprises various essential components designed to gather comprehensive information, establish care preferences, and initiate end-of-life care services for patients. These components typically include:

• Patient information: Demographic details such as the patient's name, address, contact information, date of birth, and identification numbers.
• Medical history: Comprehensive 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 regarding the patient's primary care physician or referring healthcare provider.
• End-of-life care preferences: Documentation of the patient's preferences and directives regarding end-of-life care, including pain management, symptom control, 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.
• Family or caregiver involvement: Information regarding family members, designated healthcare proxies, or caregivers involved in the patient's care and decision-making process. This helps to ensure the best care possible for the hospice patient and mitigates family discrepancies.
• Goals and expectations: Collaboratively established goals and expectations for hospice patient care, addressing the patient's needs, desires, and desired outcomes during their end-of-life journey.
• Documentation of assessments: Initial assessments are conducted by the hospice care team, detailing the patient's physical, emotional, social, and spiritual needs.
• Legal and regulatory documents: Inclusion of 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.
• Financial and insurance information: Details related to insurance coverage, billing information, and financial considerations associated with hospice services.

The different components of hospice admission paperwork

Hospice admissions paperwork comprises various essential components designed to gather comprehensive information, establish care preferences, and initiate end-of-life care services for patients. This may be written in collaboration with a hospice nurse and a wider care team, focusing on patient-centered care. These components typically include:

• Patient information: Demographic details such as the patient's name, address, contact information, date of birth, and identification numbers.
• Medical history: Comprehensive 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 regarding the patient's primary care physician or referring healthcare provider.
• End-of-life care preferences: Documentation of the patient's preferences and directives regarding end-of-life care, including pain management, symptom control, 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.
• Family or caregiver involvement: Information regarding family members, designated healthcare proxies, or caregivers involved in the patient's care and decision-making process. This helps to ensure the best care possible for the hospice patient and mitigates family discrepancies.
• Goals and expectations: Collaboratively established goals and expectations for hospice patient care, addressing the patient's needs, desires, and desired outcomes during their end-of-life journey.
• Documentation of assessments: Initial assessments are conducted by the hospice care team, detailing the patient's physical, emotional, social, and spiritual needs.
• Legal and regulatory documents: Inclusion of 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.
• Financial and insurance Information: Details related to insurance coverage, billing information, and financial considerations associated with hospice services.

How does this note template work?

The admissions process for hospice care can be lengthy and requires thorough detail to ensure all aspects of care are discussed and can be met by both the facility and the individual. Below are the steps involved in creating a viable admissions note:

Step 1: Gather your resources

Admissions notes for hospice patients are a valuable resource and essential to keep on hand. Make sure that you have a copy of the free printable PDF when the need arises by either clicking the “Download Template” or “Use Template” button or by searching “Hospice Admission Note Template” on Carepatron's template library's search bar on the website or app.

Step 2: Gather information

Begin by collecting information about the patient. This includes their medical history, current medications, care needs, preferences, and any legal or financial documents relevant to their care.

Step 3: Identify key categories

Outline the different categories or sections that need consideration within the hospice documentation. This includes medical information, personal care needs, legal and financial aspects, facility amenities, and resident preferences.

Step 4: Consult resources

Utilize resources such as end-of-life admission guidelines, healthcare facility checklists, and regulatory requirements to ensure the checklist encompasses all essential areas.

Step 5: Medical assessment

Include items related to the patient's medical needs and comfort treatment. This involves details about medical conditions, allergies, required medications, and any treatments or therapies the patient requires to attain their desired quality of life.

Step 6: Personal care needs

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

Step 7: Legal and financial documentation

Include a section for filling out legal paperwork, insurance coverage verification, financial considerations, and advance directives, ensuring all necessary legal documents are in place.

Step 8: Safely store the documentation

After reviewing the admissions notes and creating a viable and individualized plan for the patient, you need to secure the plan so that access is only granted to relevant parties. 

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

Importance of using an admission note template

A hospice documentation template can streamline the admission process, has multiple purposes, and has numerous benefits. Here's a list of some of them:

Standardized information gathering

An admissions template provides a structured format for collecting essential information about the patient's medical history, current health status, and preferences for end-of-life care, ensuring that critical details are not overlooked and that all necessary information is systematically documented.

Efficiency and time-saving

Templates streamline admissions, allowing healthcare professionals to gather pertinent information efficiently. Thus, they save time and enable quicker access to crucial details for immediate care planning and implementation.

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.

Legal and regulatory compliance

Admissions templates often incorporate regulatory requirements and legal aspects, ensuring that necessary consents, disclosures, and documentation related to hospice care, patient rights, and financial considerations are properly recorded and addressed to maintain hospice eligibility.

Facilitating communication and collaboration

Templates promote effective communication among healthcare professionals, the patient, and their families within a hospice setting. By providing a standardized format, they facilitate clearer and more cohesive exchanges, ensuring that all parties are on the same page regarding the patient’s condition, preferences, and care plan.

Enhancing quality of 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.

Who can use this template?

In addition to a cheat sheet hospice documentation template, a hospice admissions note template is primarily utilized by healthcare professionals within hospice care settings, including hospice nurses, physicians, social workers, and other members of the hospice interdisciplinary team. When a patient enters a hospice program, these professionals are involved in the admission process.

Administrative staff, including intake coordinators or admission specialists within the hospice organization, may also access and use the admissions note template. They facilitate the collection and organization of essential patient information during admission.

The admissions note template may also be shared with the patient and their family members or caregivers as part of the informed consent process. This allows them to review and understand the care plan, preferences, and policies related to hospice care, fostering transparency and communication between the care team and the patient's support network.