Date

Time In

Level of Care: Routine Home Care

A0000 = Hospice Information Set Indicator

Time Out

Inpatient

Continuous Care

1 GREEN Ink = Specific Plan of Treatment Items

(completed per agency policy)

Respite

HOSPICE INITIAL/
COMPREHENSIVE
NURSING ASSESSMENT

ADMINISTRATIVE INFORMATION - Fill Out Per Agency Policy

A0100 Facility Provider Numbers - Enter code in boxes provided

A0205 Site of Service at Admission

A. National Provider Identifier (NPI):

01. Hospice in patients home/residence

02. Hospice in Assisted Living Facility
03. Hospice provided in Nursing Long-Term Care
(LTC) or Non-Skilled Nursing Facility (NF)
04. Hospice provided in a Skilled Nursing Facility (SNF)
05. Hospice provided in Inpatient Hospital

____ ____ ____ ____ ____ ____ ____ ____ ____ ____
B. CMS Certification Number (CCN):
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

4 ID #/Medical Record No.

A0220 Admission Date/SOC

Month Day
Year
___ ___/___ ___/___ ___ ___ ___

06.
07.
08.
09.

Hospice provided in Inpatient Hospice Facility

Hospice provided in Long-Term Care Hospital (LTCH)
Hospice in Inpatient Psychiatric Facility
Hospice provided in a place not otherwise
specified (NOS)
10. Hospice home care provided in Hospice Facility

A0245 Date Initial Nursing Assessment Initiated A0250 Reason for Record
Month Day
Year
___ ___/___ ___/___ ___ ___ ___

01. Admission

3 Certification Period
From:

To:

B. Middle C. Last Name

D. Suffix
Initial
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
____
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
A0500

6 Legal Name of Patient:

A. First Name

A0700 Medicaid Number Enter + if pending, N if not Medicaid Recipient:

A0600 Social Security and Medicare Numbers

E
L

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ _____ _____ _____

A. Social Security Number

____ ____ ____- ____ ____- ____ ____ ____ ____

A0800 Gender

B. Medicare Number (or comparable railroad insurance number):

01. Male

A0900 Birth Date

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ _____

02. Female

Month Day
Year
___ ___/___ ___/___ ___ ___ ___

03.
04.
05.
06.

Skilled Nursing Facility (SNF)

Hospital Emergency Department
Short-Stay Acute Hospital (IPPS)
Long-Term Care Hospital (LTCH)

24 Primary Physicians Name

B. Asian

C. Black or African American

A1802 Admitted From - Immediately preceding this admission, where was the patient?

01. Community residential setting (e.g.,

private home/apt.,board/care, assisted
living, group home, adult foster care)
02. Long-Term Care Facility

A1000 Race/Ethnicity (Check all that apply)

A. American Indian or Alaska Native

07. Inpatient Rehabilitation

hospital or unit (IRF)
08. Psychiatric hospital or unit
09. ID/DD Facility

10. Hospice
99. None of
the above

Address

D. Hispanic or Latino

E. Native Hawaiian or Other Pacific Islander

F. White

Physicians Phone #

THE FOLLOWING ARE TO BE DISCUSSED WITH THE PATIENT AND/OR CAREGIVER PRIOR TO PROVISION OF CARE
Rights/Responsibilities
Charges for Services/Assignment of Benefits
Complaint Procedure & Hotline Number

Services Provided/Anticipated Frequency

Fire /Safety/Disaster & Emergency Plan
Advance Directives

M
A

DIAGNOSIS

Pt /Caregiver Development of Care Plan

HIPAA Information
Hospice Benefit

Policy for Managing

Controlled Drugs Given

Nature and Condition causing admission:

17 ALLERGIES: NKA

Allergic to:

11 Primary Diagnosis

Date:
O/E
a. ____________________________________________________________

13 Co-Morbidities

ICD-9-CM

(__ __ __ __ __)

ICD-9-CM

Date:
b.________________________________________________________

(__ __ __ __ __)

Reorder From:

800-438-8884

Date:
O/E
d. ____________________________________________________________
(__ __ __ __ __ __)

21 Is the patient DNR (Do Not Resuscitate)? Yes No

INH112203R

 See Bereavement Assessment/Documentation (per agency policy)

Refer to:

Terminal Care Intervention (all patients): Assess/Perform/Instruct Pt/Cg:

Spiritual, grieving & coping methods
s/s of impending death
Notification procedures for death at home
Counseling
Grief Management
Other (specify): ___________________________________________

Principal Diagnosis
01. Cancer
02. Dementia/Alzheimers
99. None of the above
I0010

Comments

Comments

KARNOFSKY PERFORMANCE STATUS SCALE (complete per agency policy)

100%
Able to carry on normal activity and to work; no special care needed
90%
80%
70%
Unable to work; able to live at home and care for most personal
needs; varying amount of assistance needed
60%
50%
40%
Unable to care for self; requires equivalent of institutional or
hospital care; disease may be progressing rapidly
30%
20%
10%
0%

2003 MED-PASS, INC.

ICD-9-CM

Date:
a.________________________________________________________

Date:
O/E
c. ____________________________________________________________
(__ __ __ __ __ __)

Patient Name (First, MI, Last)

12 Surgical Diagnosis

(__ __ __ __ __)

Date:
O/E
b. ____________________________________________________________
(__ __ __ __ __ __)

21

Last MD Visit Date: __ __/__ __/__ __ __ __

Normal no complaints; no evidence of disease

Able to carry on normal activity; minor signs or symptoms of disease
Normal activity with effort; some signs or symptoms of disease
Cares for self; unable to carry on normal activity or to do active work
Requires occasional assistance, but is able to care for most personal needs
Requires considerable assistance and frequent medical care
Disabled; requires special care and assistance
Severely disabled; hospital admission necessary; active supportive treatment necessary
Very sick; hospital admission necessary; active supportive treatment necessary
Moribund; fatal processes progressing rapidly
Dead
 See Spiritual Assessment/Documentation (per agency policy)
Refer to:

A P I

21 Impending Death Interventions/ Imminence of Death: NA

Educate caregiver/family regarding:
Signs/Symptoms of impending death Home death procedure
Interventions caring for dying patient Planning for funeral arrangements
Comments

ID No.

of 8
Form # HC8100

(Rev. 04/14)

DIAGNOSIS (continued)
Advance Directives:
Intent:

Yes

No

Yes

Patient given advance directives information?

No

Comments

DNR Medical Power of Attorney Name: _______________________________ Phone _____________

Living Will Other (specify); _____________________________________________________________

Copies on File at Agency? Yes No

Copy requested? Yes No Result: _______________________

F2000 A. Was the patient/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? Select the most accurate response
0. No 1. Yes, and discussion occurred (specify): ____________________________________________________________________________________________
___________________________________________________________________________________________________________________________
2. Yes, but the patient/responsible party refused to discuss

B. Date the patient/responsible party was first asked about preference regarding the use of CPR:

___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)

A. Was the patient/responsible party asked about preferences regarding life-sustaining treatments other than CPR? Select the most accurate response
0. No 1. Yes, and discussion occurred (specify): ____________________________________________________________________________________________
___________________________________________________________________________________________________________________________
2. Yes, but the patient/responsible party refused to discuss
F2100

B. Date the patient/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:

___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)

A. Was the patient/responsible party asked about preference regarding hospitalization? Select the most accurate response
0. No 1. Yes, and discussion occurred (specify): ____________________________________________________________________________________________
___________________________________________________________________________________________________________________________
2. Yes, but the patient/responsible party refused to discuss
F2200

B. Date the patient/responsible party was first asked about preference regarding hospitalization:

E
L

___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)

SPIRITUAL/EXISTENTIAL
21 Spiritual Need Interventions: Assess/Perform/Instruct Pt/Cg:
Spiritual needs of the patient and caregiver
Current clergy support

A P I

A P I

Need for spiritual counselor to provide spiritual support

Other: __________________________________________

F3000 A. Was the patient and/or caregiver asked about spiritual/existential concerns? Select the most accurate response
0. No 1. Yes, and discussion occurred (specify): ____________________________________________________________________________________________
___________________________________________________________________________________________________________________________
2. Yes, but the patient/responsible party refused to discuss

B. Date the patient and/or responsible party was first asked about spiritual/existential concerns:

LIVING ARRANGEMENTS

___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)

High-Risk Factors and Complications Affecting Care Plan:

Alcohol dependency
Drug dependency
Cultural/Religious practices that may impact care
Heavy smoking Chronic conditions Obesity Other (describe):_________________________
Emergency Contact Person:

M
A

Name:

(Not living with patient)

Household Composition: Lives alone With spouse or significant other

Marital Status: Single
Other family member With friend Other (specify):_______________
Divorced
Comments

Comments

Phone:

Married
Widowed
Separated Unknown

Family Supportive:

Yes
No

Family Knowledge and Coping Level Regarding Present Diagnosis/Prognosis:

Caregiver Name:

21 Volunteer Interventions: Assess/Perform/Instruct Pt/Cg:

Need for Volunteer Services
Volunteer Coordinator will:
Explain volunteer services
Arrange for the provision of requested services
Maintain supportive relationship with patient/caregiver
Other (specify): __________________________________________

A P I

Comments

A P I
21 Caregiver Relief Interventions: Assess/Perform/Instruct Pt/Cg:
Need for Caregiver Relief

Change level of care to inpatient respite care per physician order

Encourage caregiver rest during patients respite care
Provide education regarding resources and/or alternate placement
Other (specify): ________________________________________

Patient Name (First, MI, Last)

2003 MED-PASS, INC.

Support during transfer and ambulation

Emergency plan developed
Patient Caregiver demonstrates knowledge
and understanding of safety measures/safety
management Yes No
Equipment use/safety
Keep side rails up

Comments

Smoking materials in home

Home suitable/adaptable for care
Other (specify): _____________
__________________________

Keep pathways clear

Triage/Risk Code (Agency specific) ____________________
Safety in ADLs
_______________________________________________
Seizure Precautions
Standard Precautions/Infection Control Disaster Code (Agency specific) ______________________
Neutropenic Precautions
Fall Precautions
Comments
Other (specify):__________________
ID No.

Form # HC8100

INH112203

2
of 8

15 SAFETY MEASURES:
Anticoagulant Precautions
O2 Precautions
Slow position change
Proper position
during meals
Use of assistive devices

Comments
800-438-8884

18A FUNCTIONAL STATUS:

Amputation
Hearing
Ambulation
Shortness of Breath Weakness
with minimal exertion Other (specify):__________
Bowel/Bladder incontinence Paralysis
Difficult speech
Contracture
Decreased endurance Legally blind
Fatigue
______________________
Safety/Sanitation Hazards affecting patient: (Mark all that apply.)
Stairs
Lack of fire safety devices
Narrow or obstructed walkways
No running water, plumbing
No gas/electric appliances
Insect/Rodent infestation
Inadequate lighting, heating and cooling Cluttered/Soiled living area

Yes No
Yes No
Yes No
Reorder From:

Relationship:

Caregiver able/willing to provide all care

Caregiver able to receive/follow instructions
Caregiver able/willing to assist with ADLs and needed care

LIVING ARRANGEMENTS (continued)

FINANCIAL: Ability of Patient to handle Personal Finances: Independent Needs assistance Totally dependent
Inappropriate use of limited income (buying
Medical expenses not covered by Insurance/Medicare
non-essentials - alcohol, junk food, etc.)
Inadequate to buy necessities (food, medications, supplies, etc.)
Community Agencies/Social Service Screening

Comments

Yes No

Yes No

Altered affect (i.e., depression, grief, body image change)

Suspected Abuse/Neglect, i.e.: (Please circle)

unexplained bruises, inadequate food, fearful of family member, Cg. exploitation
of funds, sexual abuse, neglect, left unattended if needs constant supervision.

Suicide Ideation

Inadequate method to cook or shop for groceries

Community Resource Info needed to manage care

Comments

SENSORY STATUS
VITAL SIGNS: PULSE: Apical:__________ Reg Irreg
Radial:__________ Reg Irreg
VISION: WNL
Glasses

Blurred Vision
Glaucoma

TEMP.:__________ RESP.:____________
BP.: ____________ NA

Contacts: R L Other (specify): __________

Cataracts
_____________________

EARS/ NOSE/ THROAT/ MOUTH WNL

Hearing Loss? L R
Aid Used? L R
Ear Pain?
L R
Other: ______________________________________

Pharyngeal Condition: WNL

Hoarseness
Sore throat
Other: _____________________

Height _________
Weight _________

Comments

Mouth Condition: WNL

Abnormal oral mucosa appearance Gum problems Chewing problems
Dentures Difficulty swallowing Other: __________________
Comments

E
L

Severity of Symptoms: No Symptoms Mild Moderate Severe (distressed)

COMMUNICATION
WNL
Limited educational background
Pt.
Cg.
Reading or writing problems
Pt.
Cg.
Slow learner
Pt.
Cg.
Speech/Language barrier
Pt.
Cg.
Primary language _________________________________________
Interpreter needed?
Motivated to learn?
Pt.
Cg.

YES

NO

Neurological WNL
Dizziness
PERRL
Seizures
Headache (describe location, duration): _________________________________________
____________________________________________________________________________
Other (specify): _____________________________________________________________
Comments

MUSCULOSKELETAL WNL
Independent Requires assistance Total dependence
Bed bound
Limited ROM (give location): ___________________________________________________
Bone or joint problems________________________________________________________
Pain or cramps ______________________________________________________________
Redness, warmth, swelling ____________________________________________________
Decreased mobility/endurance __________________________________________________
Tremors ___________________________________________________________________
Amputation of ______________________________________________________________
Prosthesis/Appliance_________________________________________________________

Severity of Symptoms: No Symptoms Mild Moderate Severe (distressed)

Reorder From:

800-438-8884

Comments

PATIENT SAFETY/FALL RISK ASSESSMENT

Level of Consciousness/Mental Status
0 - Alert - (oriented x 3) or Comatose
2 - Disoriented x 3 at all times
4 - Intermittent confusion
Score ____
History of Falls (past 3 months)
0 - No falls (in past 3 months)
2 - 1-2 falls (in past 3 months)
4 - 3 or more falls (in past 3 months)
Score ____
Ambulation/Elimination Status
0 - Ambulatory/Continent
2 - Chairbound
4 - Ambulatory/Incontinent

INH112203

Score ____
Vision Status
0 - Adequate (with or without glasses)
2 - Poor (with or without glasses)
4 - Legally Blind
Score ____
Patient Name (First, MI, Last)
2003 MED-PASS, INC.

Patient Caregiver Learning Preferences:

Verbal
Written
Visual aides
Other (specify): ____________________________
Comments

21 ADL Interventions: Assess/Perform/Instruct Pt/Cg:

A P I

21 Neurological Interventions: Assess/Perform/Instruct Pt/Cg:

s/s of seizure activity
Medication administration, side effects and response
Care of patient experiencing seizures
Other (specify): ________________________________________

M
A

Severity of Symptoms: No Symptoms Mild Moderate Severe (distressed)

Comments

P I

21 Mobility Interventions: Assess/Perform/Instruct Pt/Cg:

A P I
Safe transfers

Provide assistive devices (specify): _________________________
Encourage activity as tolerated
Other (specify): ________________________________________

Caregiver ability to provide personal care

Basic personal care techniques and activities of daily living (ADLs)

Provide hospice aide personal care, frequency:_________________

Other (specify): _________________________________________

Gait/Balance
Have patient stand on both feet without holding onto anything, walk straight
forward; walk through a doorway; and make a turn.
(Mark all that apply.)
0 - Gait/balance normal
1 - Balance problem while standing
1 - Balance problem while walking
1 - Decreased muscular coordination
1 - Change in gait pattern when walking through doorway
1 - Jerking or unstable when making turns
1 - Requires the use of assistive device
(cane, wheelchair, furniture, etc.)
Score ____
Medications
Respond below based on the following types of medications: anesthetics,
antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics,
diuretics, hypoglycemics, narcotics, psychotropics, sedatives.
0 - None of these medications taken currently or w/in the last 7 days
2 - Takes 1-2 of these medications currently and/or w/in last 7 days
4 - Takes 3-4 of these medications currently and/or w/in last 7 days
1 - If patient has had a change in medications and/or change in
dosage in past 5 days = score 1 additional point.
Score ____

Systolic Blood Pressure

0 - No noted drop between lying and standing
2 - Drop, < 20mmHg between lying and standing
4 - Drop, > 20mmHg between lying and standing
Score ____
Predisposing Diseases
Respond below based on the following predisposing conditions:
hypotension, vertigo, CVA, Parkinsons disease, loss of limb(s),
seizures, arthritis, osteoporosis, fractures
0 - None present
2 - 1-2 present
4 - 3-4 or more present
Score ____
TOTAL SCORE ________
(Total score of 10 or higher represents High Risk for Falls)
(Refer to Hospice Policies and Procedures for additional instructions)

21 Fall Prevention Interventions: Assess/Perform/Instruct Pt/Cg:

A P I

Fall Prevention

Other (specify): _____________________
Comments

ID No.

of 8
Form # HC8100

PAIN
J0900

A. Pain Screen: 0. No 1. Yes

Comments

WONG-BAKER FACES1 PAIN RATING SCALE

B. Date of first screening for pain: __ __/__ __/__ __ __ __ (Month/Day/Year)

C. Patients Pain Severity
0. None
2. Moderate
1. Mild
3. Severe

Hurts
Little Bit

Hurts
Little More

Hurts
Even More

Hurts
Whole Lot

Hurts
Worst

10

9. Pain not rated

D. Type of standardized pain screen tool used:

1. Numeric
3. Patient Visual
9. No standardized tool used
2. Verbal descriptor 4. Staff Observation
J0910

No Hurt

A. Comprehensive Pain Assessment: 0. No

1From Hockenberry MJ, Wilson D: Wongs essentials of pediatric nursing, ed. 8,

St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.

1. Yes

Patient/Family goal for pain management: __________________________________

Current pain management & effectiveness: _____________________________________
Is patient uncomfortable due to pain? Yes No
Unable to self report
< age 18
Language barrier

B. Date: __ __/__ __/__ __ __ __ (Month/Day/Year)

Pain history and treatment:_________________________________________________
Onset date: __ __/__ __/__ __ __ __

 See Pain Assessment/Documentation (per agency policy)

Refer to:

Pain precipitated by: Activities Care Treatment

C. Comprehensive Pain Assessment includes:
1. Primary Location and Radiation: ______________________________________
2. Severity (See Patients Pain Severity rating above)
Other (specify): ________________________________________________
3. Pain character: Sharp Dull
Throbbing Aching Burning
Deep Superficial Other (specify): _______________
4. Pain duration: ___________________________________________________
5. Pain frequency: Constant Intermittent Other (specify): ____________
6. Pain relieved by: ___________________________________________________
Pain worsen by:___________________________________________________
Additional symptoms associated with pain:
Nausea
Vomiting Other (specify): _________________________
Strategies/Factors that reduce pain: ____________________________________
7. Effect of Pain on quality of life: Sleeping Appetite Mood
Functioning (specify):______________ Other (specify): ______________
9. None of the above

Comments

21

Pain Management Interventions: Assess/Perform/Instruct Pt/Cg:

Pain status
Response to medications
Non-Pharmacological pain control measures, e.g., relaxation,
positioning, massage, etc.
Other (specify): ___________________________________________

KEY -

TYPE: 1-Skin Lesion

2-Pressure Ulcer
3- Stasis Ulcer

4-Surgical Wound
5-Other (specify)

SIZE:

U-Undermining
T-Tunneling

(LxWxD) cm

Type Location

Size
L_____ W_____ D_____cm
L_____ W_____ D_____cm

Need for inpatient care for pain/symptom control

Patient/caregiver regarding inpatient care
Arrange transfer to inpatient facility per physician order
Other (specify): ___________________________________________

Comments

Skin: Wounds Ulcers Incision Rashes

Ostomy Other (specify): ___________________
Nails: Normal Problems

Yes No

WOUND BED:
Tissue: (List all that apply)
Color: 1-Red 3-White 5-Black 7-Other (specify)
1-Bloody 3-Sloughing 5-Eschar
2-Pink 4-Gray
6-Tan
2-Pale
4-Necrotic
6-Granular
AMOUNT:
DRAINAGE:
1-None 3-Moderate 5-Other (specify)
1-Bloody
3-Serous 5-Other (specify)
2-Serosanguineous 4-Purulent
2-Scant 4-Copious

Wound Bed
Drainage
U T Color: ________
________cm Tissue:________
U T Color: ________
________cm Tissue:________

Amount

Odor

Stage

Surrounding Skin

U T Color: ________
________cm Tissue:________
U T Color: ________
________cm Tissue:________

1 2 3 4 5 6

STAGE:
I II III IV
SURROUNDING SKIN:
(List all that apply)
1 - Pink
2 - White
3 - Red
4- Pale
5 - Warm
6 - Cool
7 - Blanched
8 - Shiny
9 - Edematous
10-Other (specify)

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R

R
L
1 2 3 4 5 6

7 8 9 10 11 12 13 14 15 16

L
R
7 8 9 10 11 12 13 14 15 16

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R

A P I
Incisional care as follows: ___________________________________
___________________________________________________________________
s/s of complications, infection to include: ________________________

Other (specify): ___________________________________________

Provide appropriate air mattress

800-438-8884

A P I
21 Integumentary Interventions: Assess/Perform/Instruct Pt/Cg:
Skin breakdown and prevention

Wound care as follows: _____________________________________

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Stoma care as follows:_____________________________________
_____________________________________________________________________

Comments

RESPIRATORY STATUS
J2030

A. Shortness of Breath Screen 0. No 1. Yes

B. Date of first screening for shortness of breath __ __/__ __/__ __ __ __ (Month/Day/Year)

Reorder From:

L_____ W_____ D_____cm

7-Weeping 9-Other (specify)

8-Healthy
ODOR:
1-Foul
3-None
2-Sweet
4-Other (specify)

P I

Severity of Symptoms:
No Symptoms
Moderate
Mild
Severe (distressed)

Instructed on Standard Precautions: Yes No

S
L_____ W_____ D_____cm

E
L

21 General Inpatient Care: Assess/Perform/Instruct Pt/Cg:

M
A

Instructed on measures to control infections:

P I

INTEGUMENTARY STATUS
Skin Turgor: Good
Fair
Poor
Skin Color: Pink/WNL Pale
Jaundice Cyanotic
Skin:
Dry
Diaphoretic Warm
Cool

Severity of Symptoms: No Symptoms

Moderate

Mild
Severe (distressed)

Comments
C. Did the screening indicate the patient had Shortness of Breath? 0. No 1. Yes
When does the patient have shortness of breath?
With minimal exertion At rest Other (specify): ________________________________________________

of 8 Patient Name (First, MI, Last)

2003 MED-PASS, INC.

Cough ___________________
Smoke ___________________
Sputum __________________
Orthopnea ________________
Breath Sounds ______________

Hemoptysis ____________________
Cyanosis ______________________
Tracheostomy (size):______________
Other (specify): ___________________

Comments

INH112203

RESPIRATORY
WNL
Breathing:
Unlabored Labored
Shallow Irregular
Cheyne-Stokes
Apnea
O2 at ____ O2 Sat ____

ID No.

Form # HC8100

RESPIRATORY STATUS (continued)

J2040

0. No

A. Was treatment for Shortness of Breath initiated? Select the most accurate response

B. Date treatment for Shortness of Breath initiated: __ __/__ __/__ __ __ __

1. No, patient declined treatment

2. Yes

(Month/Day/Year)

C. Type(s) of treatment for Shortness of Breath initiated: (Per physician order, options 1, 2 and 3)
1. Opioids 2. Other medication: ______________________ 3. Oxygen 4. Non-medication (specify): _________________________________________
21 Respiratory Interventions: Assess/Perform/Instruct Pt/Cg:

Respiratory status
Proper and safe use of O2 administration at ___________ liters/min,
via __________________________. Hours of use ______________
Response to medications and treatment
Nebulizer inhalation treatment with: __________________________

Suctioning technique
Trach care
Pulse Oximetry PRN for respiratory assessment
Other (specify): ______________________________________

CARDIOVASCULAR STATUS
Cardiovascular: WNL
12 Pacemaker : __ __/__ __/__ __ __ __ (Date inserted)
Palpitations
Fatigues easily
Poor capillary refill
Chest pain
Other (specify: ________________________________________________
Heart Rate: WNL
Edema: Pedal R/L Dependent __________
Regular
Irregular
Pitting +1 /+2 /+3 /+4 (site) __________________
Tachycardia
Bradycardia
Non-pitting (site) ___________________________
Severity of Symptoms: No Symptoms Mild Moderate Severe (distressed)

21

Cardiovascular Interventions: Assess/Perform/Instruct Pt/Cg:

Cardiovascular status
Edema, fluid retention and dehydration
s/s of infection
Other (specify): _________________________________

Comments

A P I

E
L

RENAL/GENITOURINARY STATUS

URINARY WNL
Severity of Symptoms: No Symptoms Mild Moderate Severe (distressed)
Urinary Color __________ Amt.________ Odor _______________
Hematuria Oliguria Polyuria Burning Foley Catheter Suprapubic Catheter Condom Catheter Comments
Retention: Cramping Dysuria Sediment Incontinence UTI
21

Renal/Genitourinary Interventions: Assess/Perform/Instruct Pt/Cg:

A P I
Urinary status

Skin breakdown and prevention

Condom catheter application and use

Foley catheter ______ Fr. _________ mL balloon

Foley irrigation: ___________________________________________
__________________________________________________________________

Solution ____________________ mL ________ Frequency: ______

Suprapubic catheter care: size ___________
Catheter Care - frequency: ___________
Catheter change q ___________ with ______________ Fr
_______ mL balloon catheter
Other (specify): _______________________________________

Severity of Symptoms: No Symptoms

ENDOCRINE WNL
Able to draw up insulin
Y N
Moderate
Diabetes
Able to administer insulin Y N
Neuropathy/Radiculopathy
Insulin Dependent? How long? ________________ Comments
Blood sugar glucometer use
Most recent FBS: _______________________________
Oral hypoglycemic agent
Additional information/needs: ______________________________________________

M
A

Mild
Severe (distressed)

GASTROINTESTINAL STATUS

Nausea/Vomiting
Abdominal pain
Ascites
Abnormal stool characteristics
Diarrhea/Constipation

INH112203

Reorder From:

800-438-8884

Comments

Use/Abuse of laxatives
Stool incontinence
Absent or minimal bowel sounds
Abdominal masses
Abdominal distention or tenderness

Enteral feedings
Type/Tube:__________
Changed:___________
Amt.: _____________

Size: _____________
Formula:___________
Freq.: _____________

Flow control device

Bolus
Ostomy location: ____________________
Problems associated with ostomy

Severity of Symptoms:
No Symptoms Mild Moderate Severe (distressed)

Bowel: WNL Last BM : __ __/__ __/__ __ __ __ Usual Frequency: ________________________

Bowel Sounds: Hypoactive Hyperactive Diarrhea
Constipation: Chronic Acute Occasional
Abnormal stools: Gray
Tarry Fresh blood
Hemorrhoids: Internal External
21

GI Interventions: Assess/Perform/Instruct Pt/Cg:

A P I
Nausea/Vomiting

Medication administration, side effects and response

Nutritional changes and needs related to terminal illness

Risk of aspiration

Parenteral Nutrition and the care/use of equipment to include: _____

_______________________________________________________________
_______________________________________________________________
Enteral Nutrition and the care/use of equipment to include ________
_______________________________________________________________
_______________________________________________________________
Gastrostomy Tube (specify): _____________________________
NG Tube (specify): _____________________________________
J Tube (specify): _______________________________________
Change feeding tube: ___________________________________

using size ______________________________ q ____________
Other (specify): ________________________________________

Patient Name (First, MI, Last)

2003 MED-PASS, INC.

Lax /enema use: Type ________

21 Bowel Interventions: Assess/Perform/Instruct Pt/Cg:

A P

Bowel status

Nutrition, hydration and activity

Fecal impaction and disimpact PRN

Bowel regimen initiated or continued per physician order

and effectiveness

Ostomy care to include: ________________________________

_____________________________________________________________
_____________________________________________________________
S/S enema PRN constipation

S/S Fleet enema PRN constipation

Medication administration, side effects and response

Skin breakdown and prevention

Other (specify): _______________________________________

ID No.

5
of 8

Form # HC8100

GASTROINTESTINAL STATUS (continued)

NUTRITION/HYDRATION Diet: _______________________________________________________________________________________________________________________
Difficulty chewing/swallowing (Reason): ______________________________________________ Severity of Symptoms:
No Symptoms Mild Moderate Severe (distressed)
Dentures: Upper Lower
Cachexic
Enteral/Parenteral nutrition
Recent weight gain or loss - Amt.:_________ BMI: ____________________________
Fluid intake: ___________________________________________________________

21

Comments

A P I

Patient Food Preferences: _______________________________________________________________

16 NUTRITIONAL REQUIREMENTS NEW OR CHANGED:

Impaired Swallowing Interventions Assess/Perform/Instruct Pt/Cg:

Patients swallowing ability
Medication administration, side effects and response
Alter diet as patients condition deteriorates, per physicians order
Other (specify): _______________________________________

________ Sodium Diet

________ Calorie ADA Diet
Bland Diet
________ Protein High Diet _________________ / Low Diet __________________
________ Carbohydrate High Diet _______________ / Low Diet _______________
Enteral Feeding ____________ Amount _____mL/day Pump Type: _____________

Mechanical (Soft, High-Fiber, etc.) NG Tube

Regular
Gastrostomy Tube
Supplement
J Tube
Other (specify): _________________________________________________

PSYCHOLOGICAL/MENTAL/EMOTIONAL/BEHAVIORAL STATUS
19 PSYCHOLOGICAL STATUS/BEHAVIOR WNL
Orientation: Person
Place
Time
Confused
Withdrawn
Combative
Forgetful
Depressed Agitative
Restless
Disoriented
Tearful
Hostile
Drowsy
Anxiety
Sleep Disorder Emotional Distress
Patient able to understand and participate in care

Level of Consciousness
Severity of Symptoms:
No Symptoms Mild Moderate Severe (distressed)
Semi-Comatose
Comatose
Comments
Lethargic
Other (specify): ___________
________________________

E
L

Patient knowledge and coping level regarding present diagnosis/prognosis: _______________________________________________________________________________

__________________________________________________________________________________________________________________________________________
21 Psychological/Mental/Emotional Interventions: Assess/Perform/Instruct Pt/Cg:
Level of consciousness/orientation
Safety measures to prevent injury
Current medications/potential side effects causing alteration in mental status
Causes, e.g., infection, pain, urinary retention, constipation, etc.

A P

21 Sleep Interventions: Assess/Perform/Instruct Pt/Cg:

Causes of interruptions in sleep
Medication administration, side effects and response
Other (specify): _________________________________________________

A P I

Comments
Comments

M
A

MEDICATIONS

10 MEDICATIONS: DOSE/FREQUENCY/ROUTE: See Medication Profile located ___________________

N0500 Scheduled Opioid
A. Was a scheduled opioid initiated or continued? (Per physician order)
0. No
1. Yes

B. Date:

___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)

N0510 PRN Opioid

A. Was a PRN opioid initiated or continued? (Per physician order)
0. No
1. Yes

P I

See Drug Regimen Review located ____________________

N0520 Bowel Regimen - Complete only if N0500A or N0510A = 1

A. Was bowel regimen initiated or continued? (Per physician order)
0. No
1. No, a bowel regimen was not initiated or continued (specify): __________________
___________________________________________________________________
2. Yes

B. Date:

___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)

IV Access Present:

___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)

A P I

21 High Tech/Special Procedures: Assess/Perform/Instruct Pt/Cg:

Administration of ________________ (IV medication) in _________
(solution) to run at ______ mL/hr via ___________ (Pump/Gravity)
Flush IV/PICC/Midline with 5-10mL of NS before and after antibiotic
infusion. Follow with 3-5mL Heparin _____ units/mL flush
Change _________________ dressing q _________ and PRN using
sterile technique with alcohol/betadine
Change injection cap q ___________ and PRN
Flush ________________catheter with _______________________

A P I

Central: Define _____________________________

Date Inserted: ____/____/______

A P I
If misuse or diversion is suspected:
Maintain medication in a lock box

Count medications every nursing visit

Other (specify): ______________________________________

Change Huber needle q ________ and PRN using sterile technique

Access port q ________ and PRN to flush with _______________
Pump/Equipment (specify): ______________________________
Equipment use/Safety
Start Peripheral IV and maintain site, q ________ or q ________
days and PRN for s/s of infiltration/infection
s/s of infiltration and emergency procedures
Other (specify): ______________________________________

800-438-8884

21 Medication Interventions: Assess/Perform/Instruct Pt/Cg:

Patients medications will be reviewed
Reorder of medications from pharmacy will be documented
Discontinued medications will be discarded per policy
Report to physician and IDG any medication discrepancies

Peripheral
PICC

Reorder From:

B. Date:

Counseling
Grief management
Other (specify): __________________________________

Comments

ACTIVITIES

of 8 Patient Name (First, MI, Last)

2003 MED-PASS, INC.

Independent at home
Partial weight-bearing

Cane
Crutches

Walker
Wheelchair

Other (specify): __________________

ID No.

Form # HC8100

INH112203

18B ACTIVITIES PERMITTED:

Complete bed rest
Up as tolerated
Bed rest with BRP
Transfer bed-chair

EQUIPMENT
Present Needs N/A
DME:
Hospital Bed

Trapeze Bar

Wheelchair

Pressure Relieving Device

Suction Machine

Infusion Pump

Oxygen

Ambulation Aids

Walker

Cane

Crutches
Transfer Equipment

14

Present Needs N/A

Bathroom Safety Devices
Grab Bars
Tub Stool/Shower Bench
Bedside Commode
Toileting Aids/Seat
Ramps/Railings
Other (specify): ____________
Dressing Aids
Colostomy/Ileostomy Bags
Catheter
Pacemaker
Prosthetic Device
Leg Brace
Other (specify):_____________

21 Equipment Interventions: Assess/Perform/Instruct Pt/Cg:

Use of equipment
21

A P I

DISPOSABLES:
Diabetic Supplies
Dressing Supplies
IV Supplies
Catheter Supplies
Other (specify): ___________
__________________________
__________________________
__________________________
__________________________
__________________________

Present Needs N/A

Comments

A P I
Other (specify): __________________________________________________

ORDERS FOR DISCIPLINE AND TREATMENTS

SN visit frequency ____________ and ____________ PRN for changes

in status within _____________ period of time.
Assess VS & all body systems, knowledge of disease process and its
associated care and treatment, med regimen knowledge, and s/s complications
necessitating medical attention PRN.
Assess/manage pain and discomfort and provide symptom relief

Implement and Instruct Medication Regimen, including dosage, side effects, name, route,
frequency, desired action, adverse reactions, and medication compliance/med set-up.
Patient/caregiver may administer medications
RN may perform pronouncement of death
Other (specify): __________________________________________________________
______________________________________________________________________

E
L

Aide visit frequency _____________________________________ to assist w/personal care/ADLs/light housekeeping as needed within ________________ period of time
PT visit frequency __________________ within _____________ period of time
SW to evaluate and assess for needs _________________ times per month and
PRN for counseling within ______________________________ period of time
PT to consult, evaluate and treat
Dietary counseling PRN within ___________________________ period of time
OT visit frequency __________________ within _____________ period of time
Volunteer for respite PRN within __________________________ period of time
OT to consult, evaluate and treat
Spiritual Care Coordinator visit frequency ___________________ and PRN for
ST visit frequency __________________ within _____________ period of time
spiritual support within _________________________________ period of time
ST to consult, evaluate and treat
Additional Orders (specify):_____________________________________________________________________________________________________________________
22 GOALS/OUTCOMES

INH112203

Reorder From:

800-438-8884

TERMINAL CARE/IMPENDING DEATH: Caregiver/Family will understand signs and symptoms of dying process prior to patients death
Patient/Caregiver will receive requested volunteer service within ______ days of request
VOLUNTEER SERVICES:
Caregiver will receive sufficient rest during patients terminal illness
Seizures will be controlled during care within ________________________________________________ period of time
NEUROLOGICAL:
Patient will remain safe from injury during seizure activity
Patient will maintain optimal mobility during care within ________________________________________ period of time
MOBILITY:
Optimal hygiene will be maintained during care
ADL:
Fall Prevention will be maintained during care
FALL PREVENTION:
Patients pain will remain at comfortable level during care within __________________________________ period of time
PAIN:
Patient will receive optimal level of pain and/or symptom management on short-term basis
GENERAL INPATIENT CARE:
Skin integrity will be maintained during care within ___________________________ period of time
INTEGUMENTARY:
Patient/Caregiver will receive optimal teaching and support as cardiac and pulmonary functions change during care
CARDIO/RESPIRATORY:
Patient/Caregiver will demonstrate proper and safe use of oxygen at set-up
Patient/Caregiver will verbalize understanding of medications and treatments during care with__________ period of time
Skin will be maintained at optimal level during care within ______ period of time
RENAL/GENITOURINARY:
Patient will be free of urinary tract infection during care within __________________________________ period of time
Patients nausea/vomiting will be controlled within ___________________________________________________ period of time
GASTROINTESTINAL:
Promote optimal nutrition/hydration during care within _________________________________________ period of time
Patient/Caregiver will demonstrate ability to manage bowel routine within _________________________________ period of time
Patient will maintain optimal swallowing, and patient/caregiver understands risk during care within_______ period of time
Caregiver will demonstrate ability to cope with patients altered mental status within ________________________ period of time
PSYCHOLOGICAL /MENTAL /
EMOTIONAL:
Patient will be maintained in safe environment during care within _________________________________ period of time
Patients agitation will be controlled to a manageable level within ________________________________________ period of time
Patient will achieve optimal sleep/rest during care within _______________________________________ period of time
Patient will demonstrate or report a decrease in anxiety level during care within _____________________ period of time
Patient/Caregiver will achieve optimal grief reaction prior to patients death
BEREAVEMENT:
Spiritual needs will be met as determined by patient/caregiver during care within ____________________ period of time
SPIRITUAL:
Patient will receive prescribed medications at correct times (see Medication Profile)
MEDICATIONS:
Patient/Caregiver safely administers drugs and biologicals during care
Patient/Caregiver will receive equipment and demonstrate use at time of equipment set-up
EQUIPMENT:
Other (specify): ________________________________________________________________________________________
OTHER:
Other (specify): ________________________________________________________________________________________

M
A

Patient Name (First, MI, Last)

2003 MED-PASS, INC.

ID No.

of 8
Form # HC8100

22

GOALS/OUTCOMES (continued)

SERVICES PROVIDED THIS VISIT AND PATIENT RESPONSE:

E
L

PROGNOSIS
Does patient know diagnosis?

Yes

No

Extent of metastatic disease at first Hospice contact: Local

Regional

Widespread

N/A

Plan of Care established with (care coordination):

Medical Director:_____________________________________________________________________________________________________________________________
Social Worker: ________________________________________________________________________________________________________________________________
Attending MD: _______________________________________________________________________________________________________________________________

M
A

Patient Signature (optional per Hospice policy & procedure):

Patient Name

Record No.

23 Nursing Signature/Discipline and Date:

HOSPICE PROVIDER USE ONLY

HIS SECTION Z RECORD ADMINISTRATION - Filled Out Per Agency Policy by Person(s) completing the HIS Record on the QIES ASAP System

A.
B.
C.

Signature

Title

Sections

Date Section
Completed

Reorder From:

Z0400 Signature(s) of Person(s) Completing the Record

I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or coordinated collection of this information
on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that reporting
this information is used as a basis for payment from federal funds. I further understand that failure to report such information will lead to a 2 percentage point reduction in the
Fiscal Year payment determination. I also certify that I am authorized to submit this information by this facility on its behalf.

D.
800-438-8884

E.
F.
G.
H.
I.
J.
K.

INH112203

L.

Z0500 Signature of Person Verifying Record Completion

A. Signature:

of 8 __________________________________________________________________________________________________
2003 MED-PASS, INC.

B. Date:
___ ___/___ ___/___ ___ ___ ___ (Month/Day/Year)
Form # HC8100