Hospice providers must establish and maintain a clinical record for every individual receiving care and services.
- The record must be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval.
- The record must include all services, whether furnished directly or under arrangements made by the hospice.
- Medical records should contain enough clinical factors and descriptive notes to show the illness is terminal and progressing in a manner that a physician would reasonably have concluded that the beneficiary’s life expectancy is six months or less.
- Hospice benefit periods are unlimited as long as the above remains true and documentation of disease progression is evident.
- Generally, a beneficiary will show decline from one certification period to the next; however, this may not be the case for some beneficiaries whose condition may not run the normal course of decline and remain temporarily unchanged. However, documentation in the medical record should still show that the beneficiary has a six month prognosis.
- Documentation notes from multiple disciplines involved in the care of the beneficiary should demonstrate a picture of the beneficiary’s terminal progression. Avoid vague statement such as “slow decline” or “disease progressing” that do not clearly support the terminal progression requirements; the more objective the documentation, the better.
- When receiving a beneficiary as a transfer from another agency in the middle of a benefit period, obtain a copy of the signed certification for that benefit period from the transferring agency to complete that benefit period. Remember that the benefit period does not change due to a transfer.
- When a beneficiary’s level of care changes, the documentation should show when the change occurred and the reason for the change.
“Suggestions for Improved Documentation to Support Medicare Hospice Services” quick resource tool