NP hospice face to face note

Hospice Nurse Practitioner Face-to-Face Visit Template Patient Name: Mrs. Evelyn Carter Age/Gender: 82, Female Code Status: DNR Allergies: NKDA Admission Date: 20 October 2024 Date of Visit: 1 November 2024 Recertification Period: 60 days Benefit Period: 3 Primary Admitting Diagnosis: Metastatic Breast Cancer Other Pertinent Diagnosis: COPD, Hypertension Medications: Morphine Sulfate 10mg PO q4h PRN for pain, Lorazepam 0.5mg PO q6h PRN for anxiety, Oxygen 2L via nasal cannula Subjective: - Primary Concerns: Patient reports increased shortness of breath and worsening pain despite current medication regimen. - Family/Caregiver Input: Daughter reports increased confusion and decreased oral intake over the past week. - Patient’s Expressed Wishes (if applicable): Patient wishes to remain at home and is adamant about comfort care. Objective: - General Appearance: Frail, cachectic, appears uncomfortable. - Neurological: Confused, oriented to person only. - Respiratory: Labored breathing, scattered wheezes. - Cardiac: Regular rate and rhythm, no edema. - Gastrointestinal: Poor oral intake, bowel sounds present. - Skin: Skin is dry, with stage 1 pressure ulcer on sacrum. Assessment: - Clinical Findings: Worsening dyspnea, increased pain, decline in functional status consistent with advanced metastatic breast cancer. - Functional Status/Evidence of Decline: PPS score of 30%. Plan: - Medication Adjustments: Increase Morphine Sulfate to 15mg PO q4h PRN for pain. Add Dexamethasone 4mg PO daily for dyspnea. - Symptom Management: Continue oxygen therapy. Educate family on signs of respiratory distress and provide comfort measures. - Coordination with Hospice Team: Schedule follow-up visit in 2 days. Discuss with social worker for family support and education. Attestation: I attest that I have completed a face-to-face encounter with this patient and that the clinical findings documented above support a terminal prognosis. This documentation will be provided to the certifying physician for use in determining continued eligibility for hospice care. Upon submission of my visit note, my electronic signature will be placed on the face-to-face attestation as part of the certification of terminal illness. Signed: Dr. Jane Smith, CNP 1 November 2024