NP hospice face to face note

Hospice Nurse Practitioner Face-to-Face Visit Template Patient Name: [Insert Patient Name] Age/Gender: [Insert Age, gender] Code Status: [insert code status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergies: [insert allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Admission Date: [insert admission date] Date of Visit: [Insert Date] Recertification Period: [insert recertification period] Benefit Period: [insert benefit period] Primary Admitting Diagnosis: [insert primary admitting diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Other Pertinent Diagnosis: [insert additional diagnosis codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: [insert medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Subjective: - Primary Concerns: [Patient's current symptoms, pain levels, or any notable changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Family/Caregiver Input: [Any concerns or updates from family or caregivers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Patient’s Expressed Wishes (if applicable): [Patient's goals of care or symptom management preferences] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective: - General Appearance: [Describe patient’s overall condition, e.g., frail, cachectic, comfortable, distressed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Neurological: [Level of consciousness, orientation, responsiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Respiratory: [Breathing patterns, presence of congestion or secretions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Cardiac: [Heart rate, rhythm, presence of edema or other findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Gastrointestinal: [Nutritional intake, bowel sounds, signs of discomfort] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Genitourinary: [insert genitourinary information, bladder function, catheter status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Skin: [Condition of skin, presence of wounds, pressure ulcers, or mottling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment: - Clinical Findings: [Summarize findings consistent with terminal illness and disease progression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Functional Status/Evidence of Decline: [FAST score, PPS score, or other relevant assessment scale] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: - Medication Adjustments: [Any changes or additions to comfort medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Symptom Management: [Pain control, respiratory support, anxiety relief, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Coordination with Hospice Team: [Plan for follow-up, family education, facility coordination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 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: [Provider Name], CNP [Date] (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)