Documentation details every Hospice professional needs to know.

Saul Ebema

Documenting Increased Weakness

Previously patient;

  • Was able to pivot
  • Slept 12 of 24 hours
  • Ambulated independently with walker
  • Able to sit upright in chair
  • Able to self-propel wheelchair
  • Able to engage in 30 minutes of singing favorite songs
  • Was interested in [XYZ] activities

Now patient;

  • Unable to bear weight
  • Sleeps 18 to 24 hours
  • Ambulates with walker, but now requires assistance
  • Requires lateral arm support, support with pillows, geri chair, foot rests, etc.
  • Unable to self-propel in wheelchair
  • Only able to listen to songs; unable to sing along
  • No longer able to participate in activities

Documenting Mental Status

Is/Does the Patient:

  • Able to make needs known?
  • Recognize family members?
  • Respond to name only?
  • Wander aimlessly?
  • Stare blankly or stare off into space?
  • Respond to tactile/auditory stimuli?
  • Combative/irritable/paranoid?
  • Maintain eye contact or visually track?
  • Able to smile? Flat affect? Hold head upright?
  • Drool?
  • Laugh inappropriately?

Documenting Mealtimes

  • feed required?
  • Unable to utilize silverware?
  • Requires prompting/encouragement to accept food, chew, swallow?
  • Exhibits prolonged chewing time/difficulty swallowing?
  • Pockets food?
  • Expresses no interest in food?
  • Plays with/throws food?
  • Takes food from others’ plates?
  • Finger food only?
  • How much does patient eat? Percentages are subjective, so be specific (e.g., patient consumed 2 bites of sandwich and 4 teaspoons of Jell-O). 100 percent of a piece of toast and 6 oz of tea cannot be compared to 100 percent of a steak dinner with potatoes, salad and dessert!
  • Does the patient cough after eating or drinking?
  • Is it taking longer to feed the patient?
  • Is the patient refusing food?

Documenting Observations

Is Patient’s Speech:

  • Nonsensical?
  • Responds to yes/no questions only?
  • Garbled?
  • Inappropriate responses?
  • Is speech repetitive?
  • Sing-song?

Documenting Weight Loss:

  • Is the patient’s weight being recorded. Is there a decline?
  • Is weight loss evidenced by loose-fitting clothes, belt that is now too big, and/or extra skin folds?
  • Are bony prominences evident or is patient skeletal in appearance?
  • Does the patient look thinner when compared to a photo taken in healthier days?

Documenting Ambulation/Transfers:

  • Requires standby, one or two person assist?
  • Requires Hoyer lift?
  • Does patient lean to the side in wheelchair? (This relates to FAST score 7d and indicates patient cannot maintain posture.)
  • Has patient lost the strength to lift feet off the ground when transported in a wheelchair?
  • Does patient need a geri chair or Broda chair?



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