Palliative Care & Hospice

Relevant documentation may include physician certifications, diagnoses, functional decline, nutritional or weight changes, hospitalizations, disease progression, treatment history, hospice assessments, and recertification records. For Medicare hospice coverage, the record must support a physician-certified prognosis of six months or less if the terminal illness follows its normal course. Hospice may continue beyond six months when the patient remains eligible and the required recertifications are completed.

Nursing assessments, medication administration records, physician orders, dose changes, and documented treatment responses can show how pain, shortness of breath, agitation, nausea, anxiety, secretions, and other symptoms changed over time. These records may help clarify why treatment was adjusted and how the patient responded during the final phase of care.

Progress notes, advance-care-planning records, family meetings, advance directives, and treatment decisions may document the patient’s expressed preferences, who participated in discussions, and what decisions followed. Comparing these records with subsequent treatment can help show how the care plan developed and whether later interventions were consistent with the goals documented at the time.