Comprehensive Hospice Documentation Notes

Patient Identification and Contact Information: Patient Name: John Doe DOB: 15 March 1945 Medical Record Number: 123456789 Primary Care Physician: Dr. Emily Smith (Contact: 01234 567890, emily.smith@hospital.org) Hospice Nurse: Sarah Johnson, RN (Contact: 09876 543210, sarah.johnson@hospice.org) Emergency Contact: Jane Doe, spouse, Contact: 01234 098765 Limits of Care and Assistance Needs: John requires assistance with mobility and meal preparation. He has declined interventions such as IV fluids and mechanical ventilation. He prefers to receive care at home with a focus on comfort and quality of life. Advance Directives and Care Preferences: Advance Directive on file, last updated: 1 October 2024. POLST form signed, indicating DNR and DNI. The patient requests oral pain relief and prefers to have family present at home. Spiritual support includes weekly visits from a local pastor. Care Team Roles and Responsibilities: Dr. Emily Smith is the medical decision-maker. Sarah Johnson, RN, manages medications and visits twice weekly. Jane Doe receives family updates and is informed of any changes. Symptom and Pain Management Plan: Current pain level: 4/10 as reported by the patient. Medication plan: - Morphine 10mg, oral, every 4 hours for pain management - Lorazepam 1mg, oral, twice daily for anxiety management - Lisinopril 10mg, oral, daily - Non-medication approaches: warm compresses and guided breathing exercises Emergency and Catastrophic Orders: In the event of rapid decline, administer pre-prepared comfort medications: - Morphine 20mg for distress - Midazolam 5mg for agitation - Glycopyrrolate 0.2mg for secretion management If unresponsive and in distress, reposition for comfort and ensure family presence. No hospital transfers or resuscitative measures per patient’s directive. Family and Caregiver Communication Plan: Most recent family meeting: 25 October 2024. Jane Doe, spouse, informed of current care plan and emergency protocols. Jane to receive weekly updates via email. If significant changes occur, family will be notified within 24 hours. Legal and Compliance Documentation: Signed DNR order on file – dated 1 September 2024. Power of attorney assigned to Jane Doe, confirmed by legal documentation. Insurance: Medicare, hospice benefit active All documents reviewed and compliant with state hospice regulations. Next review scheduled for 1 December 2024.