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?



Hospice Chaplaincy is a nonprofit organization committed to promoting excellence in spiritual care at the end of life. We are committed to the belief that people from all backgrounds, cultures and faith traditions should experience the end of life in a way that matches their own spiritual/religious values and goals. The task of dying is complicated and often confronts us with lots of spiritual, emotional and physical suffering. Hospice Chaplaincy is dedicated to providing support and professional development resources for hospice chaplains, patient advocacy, and education services to the public, to create a cultural shift to inform and transform our thinking around the psychosocial and psychospiritual issues at the end of life .

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