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Part 2 seeks to assist both new and experienced hospice nurses and other team members in meeting various requirements and documenting the specific information required by any payer; “paint a picture” of the patient’s/family’s conditions, concerns, care and responses to care, and interventions; and overall, to accurately chronicle the patient’s individualized hospice care.


The hospice clinical record is a legal document and is the only one that chronicles a patient’s stay from admission and start of hospice care through to death or discharge. If the agency has computerized clinical records, the data might be entered at the point of care with the patient and family. It is strongly recommended that the documentation be completed as soon as possible and at the time the care is provided, when possible, to ensure accuracy of the information. The care and practice of hospice team members are described every day to surveyors, peers, and managers in the hospice clinical record. Visit records, notes, and other information that appears in the record reflect the standard of hospice care as well as the unique care provided to a specific patient and family.

Hospice team members must be able to integrate the knowledge of regulatory criteria, care coordination, and practice into effective documentation that supports coverage while demonstrating quality and value to any reviewer. Third-party payers, such as the Medicare Administrative Contractors (MACs), make numerous quality and reimbursement decisions based on the care the patient received as evidenced in the hospice clinical record. Other reviewers might include accreditation bodies, state licensure surveyors, federal auditors, consultants, and others. For these reasons, hospice team members must have an effective understanding of the hospice regulatory environment and the expectations about the standards of effective hospice documentation. When in doubt, ask your supervisor about the hospice’s policies and requirements related to documentation.

The following sections discuss factors that contribute to hospice documentation.

Increased Scrutiny of Hospice Services

A clinician’s documentation plays a critical role in today’s hospice environment. Documentation of hospice care must be complete, accurate, detailed, and consistent enough to tell the patient’s and family’s story. There is huge federal and state focus on healthcare fraud and abuse as an outcome of the 2010 Affordable Care Act (ACA). This increases the probability of a hospice receiving this type of audit. These audits would be separate from a recertification or relicensure survey. Targeted audits from commercial insurance companies or payers have also risen in the past decade. The quality and comprehensiveness of documentation determines the outcome of any audit, such as those for survey and certification and licensure. Financial payback is on the line, and because of this, hospices need to educate clinicians about hospice-specific documentation regulatory requirements, identify and set documentation standards, and hold clinicians accountable for care and the ...

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