321.952.0494 General Guidelines – All Diagnoses · · 2012-11-06Documentation of clinical...

General Guidelines – All Diagnoses This worksheet is a guide for initial and re-certification assessments. It must be accompanied by narrative documentation. Construct a narrative from the information on this worksheet and from the physician and record on back. The patient should be re-evaluated at specific intervals set by the interdisciplinary team.

Patient Name: ____________________________ MR#:_____________ Date ________________

321.952.0494

The patient should meet the following criteria:

1. Life-limiting condition __Yes __No

2. Patient/family informed condition is life limiting __Yes __No

3. Patient/family elected palliative care __Yes __No

4. Documentation of clinical progression of disease __Yes __No

Evidenced by (check all that apply and secure copies of documentation for Hospice record):

__Serial physician assessment

__Laboratory studies

__Radiological or other studies

__Multiple Emergency Dept. visits

__Inpatient hospitalizations

__ Home health nursing assessment if patient homebound and/or

5. Recent decline in functional status __Yes __No

Evidenced by either:A. Karnofsky Performance Status < 50% __Yes __No

_50% Requires considerable assistance and frequent medical care

__40% Disabled; requires special care and assistance Unable to care for self; disease may be progressing rapidly

__30% Severely disabled; although death is not imminent

__20% Very sick; active supportive treatment necessary

__10% Moribund; fatal processes progressing rapidly and/or

B. Dependence in three (3) of six (6) Activities of Daily Living __Yes __No

Check activities in which patient is dependent: __Bathing __Dressing __Feeding __Transfers __Continence of urine and stool __Ambulation to bathroom and/or

6. Recent impaired nutritional status __Yes __No

Evidenced by (check all appropriate):

__ Unintentional, progressive weight loss of 10% over past six months

__ Serum albumin < 2.5 gm/dl (may be helpful prognostic indicator but should not be used by itself)

Diagnosis— Present underlying illness(es) and all other illness(es) affecting the terminal diagnosis:____________________________________________________________________________________________________________________________________________________________________________________________________________

Co-morbidity that affects the prognosis: ____________________________________________________________________________________________________________________________________________________________________________________________________________

History and progression of the illness(es): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Physical baseline (e.g., weight and weight change, vital signs, heart rhythms, rales, degree of edema):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Laboratory (if pertinent): ____________________________________________________________________________________________________________________________________________________________________________________________________________ Physician’s prognosis stating why there is a life expectancy of six (6) months or less (e.g., patient depressed, will not eat and does not want anything done, or has had optimal therapy for illness.): ____________________________________________________________________________________________________________________________________________________________________________________________________________

RN Signature Date Physician Signature Date

Narrative Summary of Prognosis DocumentationDocumentation should be complete, consistent, concise, specific, measurable, and descriptive.

Patient Name: ______________________________________ MR#:_______________________

Cardiopulmonary Disease This worksheet is a guide for initial and re-certification assessments. It must be accompanied by narrative documentation. Construct a narrative from the information on this worksheet and from the physician and record on back. The patient should be re-evaluated at specific intervals set by the interdisciplinary team.


1. Is the patient NYHA stage IV and having signs and symptoms of cardiopulmonary disease at rest?

NYHA Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.

__Yes __No Is the ejection fraction less than 20%< 20%? (only if test results available)

__Yes __No Cor pulmonale and right heart failure?

__Yes __No Resting tachycardia (heart rate > 100

beats per minute)

2. The patient is on optimal diuretic and vasodilator therapy? __Yes __No

Diuretics (Check all that apply.)__Furosemide (Lasix)__Ethacrynic Acid (Edecrin) __Bumetanide (Bumex)__Torsemide (Demedex) __Metolazone (Zarloxlyn, Mykrox)__Aldactone

Vasodilators (Check all that apply.) __Nitrates (e.g., Nitro patch, Isosorbide) __ Apresoline Anglotensin Converting Enzyme (ACE)

ACE Inhibitors(Check all that apply.) __ Benazepril (Lotensin)__ Captopril __ Enalapril (Vasotec)__ Fosinopril (Monopril)__ Lisinopril (Prinivil, Zestril) __ Quinapril (Accupril) __ Ramipril (Altace)

3. Patient has severe lung disease as documented by both a and b:

__a. Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough.

__b. Progression of end-stage pulmonary disease, as evidenced by prior increased visits to Emergency Department or prior hospitalizations for pulmonary infections and/or respiratory failure.

__ Hypoxemic at rest on room air, as evidenced by pO2 < 55 mmHg or

__ O2 saturation < 88% on room air or __ Hypercapnia (pCO2 > 50 mmHg)

4. Factors (Check all that apply.)

__ Unintentional progressive weight loss > 10% of body weight over the preceding six months

__ Treatment resistant supraventricular or ventricular arrhythmias

__History of cardiac arrest and resuscitation.

__History of unexplained syncope__Brain embolism of cardiac origin

__Concomitant HIV disease

Criteria 1, 2, and 3 are important indicators, factors from 4 will add supporting documentation.

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Patient Name: ______________________________________ MR#:_______________________

1. Patient should be at or beyond Stage 7 of the Functional Assessment Staging Scale.Check Level:

�__��7A.��Ability�to�speak�is�limited�to�1�to�5�intelligible�words�in�the�course�of�a�day.

�__��7B.��All�intelligible�vocabulary�is�lost.�__��7C. Ambulatory�ability�is�lost�(cannot�walk�

without�personal�assistance).�__��7D. Cannot�sit�up�independently�(e.g.,�patient�

will�fall�over�if�there�are�not�lateral�arm�rests�on�the�chair).

�__��7E. Unable�to�smile�__��7F.�Unable�to�hold�up�head

2. Patient should show all of the following characteristics. Check all that apply:

__�Unable�to�ambulate�without�assistance

__�Unable�to�dress�without�assistance

__�Unable�to�bathe�without�assistance

__��Incontinence�of�urine�and�stool�occasionally�or�constantly

__��Unable�to�speak�or�communicate�meaningfully�(see�7A�above)

DementiaThis�worksheet�is�a�guide�for�initial�and�re-certification�assessments.�It�must�be�accompanied�by�narrative�documentation.�Construct�a�narrative�from�the�information�on�this�worksheet�and�from�the�physician�and�record�on�back.�The�patient�should�be�re-evaluated�at�specific�intervals�set�by�the�interdisciplinary�team.


3. Patient must have had one of the following during the past year: (Check all that are appropriate.)

__��Aspiration�pneumonia

__��Pyelonephritis�or�other�upper�urinary�tract�infection

__�Septicemia

__�Decubitus�ulcers,�multiple,�stage�3-4

__�Fever,�recurrent�after�antibiotics

__��Inability�to�maintain�sufficient�fluid�and�calorie�intake�with�10%�weight�loss�during�the�prior�six�(6)�months�or�serum�albumin�less�than�2.5�gm/dl

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All of the following must be present as evidence of Hospice appropriateness.








Patient Name: ______________________________________ MR#:_______________________

1. Palliative Performance Scale (PPS) of < 40. (Check applicable percentage):

% Activity Work ability Self Care Level PO Intake LOC

__40 Mainly Bed Unable to do any work. Extensive Disease.

Mainly Assistance Normal or Reduced Full or Drowsy or Confused

__30 Total Bed Bound

As Above Total Care Reduced Full or Drowsy or Confused

__20 As Above As Above Total Care Minimal Sips Full or Drowsy or Coma

__10 As Above As Above Total Care Mouth Care Only Drowsy or Coma

__0 Death

321.952.0494Stroke and/or ComaThis worksheet is a guide for initial and re-certification assessments. It must be accompanied by narrative documentation. Construct a narrative from the information on this worksheet and from the Physician and record on back. The patient should be re-evaluated at specific intervals set by the interdisciplinary team.


2. Inability to maintain hydration and caloric intake with one of the following:

__ Unintentional weight loss of greater than 10% over prior six months

__ Unintentional weight loss of greater than 7.5% over prior three months

__ Serum albumin 2.5 gm/dl

__ Current Hx of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events

__ Calorie counts documenting inadequate caloric/fluid intake

If the patient does not meet both medical criteria #1 and #2, the documentation should describe relevant co-morbidity and/or rapid decline.

3. Comatose patients (any etiology) with any 3 of the following on day 3 of coma:

__ Abnormal brain stem response

__ Absent verbal response

__ Absent withdrawal response to pain

__ Serum creatinine > 1.5mg/dl





Laboratory (if pertinent): ____________________________________________________________________________________________________________________________________________________________________________________________________________ Physician’s prognosis stating why there is a life expectancy of six (6) months or less (e.g., Patient depressed, will not eat and does not want anything done, or has had optimal therapy for illness.): ____________________________________________________________________________________________________________________________________________________________________________________________________________



Patient Name: ______________________________________ MR#:_______________________

For Acute and Chronic renal failure, 1,2, and 3 must be present. Factors from 4 will lend supporting documentation.

Acute Renal Failure1.__�The�patient�is�not�seeking�dialysis��

or�renal�transplant2.__�Creatinine�clearance�of�<�10cc/min��

(<15cc/min for diabetics)3.__�Serum�creatinine�>�8.0�mg/dl�

(> 6.0 mg/dl for patients with diabetics)

321.952.0494Renal DiseaseThis�worksheet�is�a�guide�for�initial�and�re-certification�assessments.�It�must�be�accompanied�by�narrative�documentation.�Construct�a�narrative�from�the�information�on�this�worksheet�and�from�the�physician�and�record�on�back.�The�patient�should�be�re-evaluated�at�specific�intervals�set�by�the�interdisciplinary�team.


Acute Renal Failure Comorbid Conditions

__�Mechanical�ventilation

__ Immunosupppression/AIDS

__Malignancy�of�other�organ�system

__Sepsis

__Chronic�lung�disease

__ Albumen�<�3.5gm/dl

__�Advanced�cardiac�disease

__ Cachexia

__Advanced�liver�disease

__ Platelet�count�<�25,000

__Intractable�fluid�overload

__ Disseminated�intravascular�coagulation

__Gastrointestinal�bleeding�

Chronic Renal Failure

�1.�__ The�patient�is�not�seeking�dialysis�or�renal�transplant

�2.�__ Creatinine�clearance�of�<�10cc/min�(<15cc/min�for�diabetics)

�3.�__ Serum�creatinine�>�8.0�mg/dl�(>�6.0�mg/dl�for�diabetics)

Chronic Renal Failure signs and symptoms

__ Uremia

__ Oliguria�(<400�cc/Day)

__��Intractable�hyperkalemia�(>7.0)�not�responsive�to�treatment

__ Uremic�pericarditis

__ Hepatorenal�syndrome

__ I�ntractable�fluid�overload,�not�responsive�to�treatment








Patient Name: ______________________________________ MR#:_______________________

Criteria 1 and 2 must be present; factors from 3 will lend supporting documentation.

1. The patient should show both a and b:

__ A. Prothrombin time prolonged more than 5 seconds over control, or INR >1.5

__ B. Serum albumin <2.5 gm/dl

2. End-stage liver disease is present and the patient shows at least one of the following:

__ ascites, refractory to treatment or patient non-compliant

__ Spontaneous bacterial peritonitis..

__ Hepatorenal syndrome with elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration < 10mEq/L

__ Hepatic encephalopathy, refractory to treatment, or patient non-compliant

__ Recurrent variceal bleeding, despite intensive therapy

321.952.0494Liver DiseaseThis worksheet is a guide for initial and re-certification assessments. It must be accompanied by narrative documentation. Construct a narrative from the information on this worksheet and from the physician and record on back. The patient should be re-evaluated at specific intervals set by the interdisciplinary team.


3. Documentation of the following factors will support eligibility for hospice care:

__ Progressive malnutrition….

__ Muscle wasting with reduced strength and endurance

__ Continued active alcoholism (> 80g ethanol per day)…..

__Hepatocellular carcinoma

__HBsAg (Hepatitis B) positivity

__Hepatitis C refractory to interferon treatment

Patients awaiting liver transplant who otherwise fit the above criteria may be certified for theHospice Benefit. If, however a donor organ is procured, the patient must be discharged fromthe Hospice Program.








Patient Name: ______________________________________ MR#:_______________________

Criteria 1 and 2 are important indicators. 1. The nutritional impairment impacts the

patients Body Mass Index (BMI):A. BMI below 22.B. Patient is declining enteral/parenteral nutritional

support or has not responded to such nutritional support, despite an adequate caloric count

Failure to Thrive (Adult)This worksheet is a guide for initial and re-certification assessments. It must be accompanied by narrative documentation. Construct a narrative from the information on this worksheet and from the physician and record on back. The patient should be re-evaluated at specific intervals set by the interdisciplinary team.


% Activity Work Ability Self Care Level Intake LOC

40 Mainly Bed Unable to do any work. Extensive Disease.

Mainly Assistance Normal or Reduced

Full or Drowsy or Confused

30 Total Bed Bound

As Above Total Care Reduced Full or Drowsy or Confused

20 As Above As Above Total Care Minimal Sips Full or Drowsy or Coma

10 As Above As Above Total Care Mouth Care Only Drowsy or Coma

Karnofsky

Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.

40 Disabled; requires special care and assistance.

30 Severely disabled; hospital admission is indicated although death not imminent.

20 Very sick; hospital admission necessary; active support treatment necessary.

10 Moribund; fatal processes progressing rapidly.

2. The individual is significantly disabled with either A or B:___ Karnofsky of < 40% ___ Palliative Performance Scale < 40%.

Note: Anthropometry may be substituted, with documentation as to why BMI could not be measured.

step 1: Multiply weight (in lbs.) by 703step 2: Multiply height (in inches)

by height (in inches)step 3: Divide step 1 by step 2 to get your BMI

BMI (kg/m²) = Weight (kg) or

Height (m) ²

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Patient Name: ______________________________________ MR#:_______________________

Amyotrophic Lateral Sclerosis (ALS) This worksheet is a guide for initial and re-certification assessments. It must be accompanied by narrative documentation. Construct a narrative from the information on this worksheet and from the physician and record on back. The patient should be re-evaluated at specific intervals set by the interdisciplinary team.


In determining prognosis for the ALS patient, examination by a neurologist within three months of assessment is advised. All patients must meet criteria 1 and 2, or 3.

1. The patient must demonstrate critically impaired breathing capacity with all the following:

___ Vital capacity (VC) less than 30% of normal

___Significant dyspnea at rest

___Supplemental oxygen required at rest

___Patient declines artificial ventilation

2. Patient must demonstrate both rapid progression of ALS and at least one of the following life-threatening complications:

___Recurrent aspiration pneumonia

___Sepsis

___ Upper urinary tract infection (e.g., Pyelonephritis)

___Fever recurrent after antibiotics

3. Patient must demonstrate both rapid progression of ALS and critical nutritional impairment:

A. Rapid progression as demonstrated by all the following within the last 12 months:

___ Progression from independent ambulation to wheelchair or bed-bound status

___ Progression from normal to barely intelligible or unintelligible speech

___Progression from normal to pureed diet

___ Progression from independence in all or most ADL’s to needing major assistance by caretaker in all ADL’s

B. Critically impaired nutritional status as demonstrated by all the following within the last 12 months:

___Absence of artificial feeding methods

___ Oral intake of nutrients and fluids insufficient to sustain life

___Continued weight loss

___Dehydration or hypovolemia

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Patient Name: ______________________________________ MR#:_______________________

__CNS lymphoma

__Progressive multifocal leukoenephalopathy

__ Cryptosporidium infection

__ Wasting (loss of 33% lean body mass)

__ MAC bacteremia, untreated, unresponsive

to treatment, or treatment refused.

__ Visceral Kaposi’s sarcoma unresponsive

to therapy

__Renal failure in the absence of dialysis.

__ Systemic lymphoma with advanced HIV

disease and partial response to chemo-

therapy

__Toxoplasmosis: unresponsive to therapy

321.952.0494HIV DiseaseThis worksheet is a guide for initial and re-certification assessments. It must be accompanied by narrative documentation. Construct a narrative from the information on this worksheet and from the physician and record on back. The patient should be re-evaluated at specific intervals set by the interdisciplinary team.


2. Decreased performance status of </= 50,as measured by Karnofsky Performance Status scale.

3. Documentation of the following factors support hospice care eligibility:

__Chronic persistent diarrhea for one year

__ Persistent serum albumin < 2.5

__ Concomitant, active substance abuse

__ Age > 50

__ Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

__ Advanced AIDS Dementia Complex.

__ Congestive Heart Failure, symptomatic at rest

__ Toxoplasmosis

Patients will be considered to be in the terminal stage of their illness (life expectancy of six months or less) if they meet the following criteria.

1 and 2 must be present.1. CD4+ Count

__< 25 cells/mcL or Viral Load

__ > 100,000 copies/mlPlus one of the following:

Complication (Check all that are present.)







Patient Name: ______________________________________ MR#:_______________________


321.952.0494 General Guidelines – All Diagnoses · · 2012-11-06Documentation of clinical...

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