BEFORE WRITING ON THIS FORM, SEPARATE INTO THREE FORMS BETWEEN PAGES 1, 2, AND 3

HOSPICE IDG MEETING /
CARE PLAN UPDATE

✓FR - Indicates Facility is responsible for

performing the respective function
Patient Name (First, MI, Last)
Current Level of Care: □ Routine Home Care

ID#
□ Inpatient □ Continuous Care □ Respite

Review Date

Change needed?  No  Yes to: __________________________________________________

During the past 15 days has the patient experienced any changes in:
Physical Needs:
□ Yes □ No Describe: _______________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Psychosocial Needs: □ Yes □ No Describe: _______________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Emotional Needs:
□ Yes □ No Describe: _______________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Spiritual Needs:
□ Yes □ No Describe: _______________________________________________________________________________________
_____________________________________________________________________________________________________________________________
NEUROLOGICAL STATUS
TERMINAL CARE/IMPENDING DEATH
Goals/Outcomes:
Goals/Outcomes: 
Caregiver/Family will understand signs and symptoms of dying process 
Seizures will be controlled  during care  within ____ period of time
prior to patient’s death 
Patient will remain safe from injury during seizure activity 
Other: _____________________________________________________ 
Other: _____________________________________________________
Progress Toward Goals/Outcomes:

Progress Toward Goals/Outcomes:

Terminal Care Interventions: (all patients) □ FR 
Assess  Perform  Instruct: Spiritual, grieving and
coping methods 
Assess  Instruct: s/s of impending death 
Instruct: Notification procedures for death at home 
Assess  Perform  Instruct: Counseling 
Assess  Perform  Instruct: Grief management 
Other: __________________________________________
Impending Death Interventions:  FR 
NA 
Educate caregiver/family regarding: 
Signs/Symptoms of impending death 
Interventions caring for dying patient 
Home death procedure 
Planning for funeral arrangements

C RC RS N 
     

C  

 
 
 
 

RC RS 
     

N 

800-438-8884

© 2006 MED-PASS, Inc.

Comments:

ANTICIPATORY GRIEF AND BEREAVEMENT
Goals/Outcomes: 
Patient/caregiver will achieve optimal grief reaction prior to patient’s death 
Other: _____________________________________________________
Progress Toward Goals/Outcomes:

Interventions:  FR 
Assess: Patient/Caregiver reaction to disease and loss 
Facilitate Life Review 
Assess: Survivor risk factors 
Establish bereavement plan of care 
Social Worker and/or Spiritual Counselor to provide
optimal interventions 
Educate regarding bereavement program 
Other: __________________________________________

C     

RC RS 
 
 
 
 


N      

  
 

Comments:

VOLUNTEER SERVICES
Goals/Outcomes: 
Patient/Caregiver will receive requested volunteer services within ___ days
of request 
Caregiver will receive sufficient rest during patient’s terminal illness 
Other: _____________________________________________________

To order forms call:

Progress Toward Goals/Outcomes:

Volunteer Interventions:  FR 
Assess  Instruct: Need for Volunteer Services 
Volunteer Coordinator will: 
Explain volunteer services 
Arrange for the provision of requested services 
Maintain supportive relationship with patient/caregiver 
Other: __________________________________________
Caregiver Relief Interventions:  FR 
Assess  Instruct: Need for Caregiver Relief 
Change level of care to inpatient respite care per
physician order 
Encourage caregiver rest during patient’s respite care 
Provide education regarding resources and/or alternate
placement 
Other: __________________________________________

C RC RS N 
  
  

C   


RC RS 
 
 

N   

  
  
 

Neurological Interventions:  FR 
Assess  Instruct: s/s of seizure activity 
Assess  Perform  Instruct: Medication administration,
side effects and response 
Assess  Perform  Instruct: Care of patient experiencing
seizures 
Other: __________________________________________

C RC RS N 
  
  
  
 

Comments:

MUSCULOSKELETAL STATUS
Goals/Outcomes: 
Patient will maintain optimal mobility  during care  within _______
period of time 
Optimal hygiene will be maintained during care 
Fall Prevention will be maintained during care
Progress Toward Goals/Outcomes:

Mobility Interventions: 
FR 
Assess  Perform  Instruct: Safe transfers 
Provide assistive devices (specify): ___________________ 
Encourage activity as tolerated 
Other: __________________________________________
ADL Interventions:  FR 
Assess: Caregiver ability to provide personal care 
Assess  Instruct: Basic personal care techniques and
activities of daily living (ADLs) 
Provide hospice aide personal care, frequency: __________ 
Other: __________________________________________
Fall Interventions:  FR 
Assess  Perform  Instruct: Fall prevention 
Other: __________________________________________

C    

C  

RC RS N 
  
  
  
 
RC RS N 
 
  

C   

  
 
RC RS N 
 


Comments:

PAIN STATUS
Goals/Outcomes: 
Patient’s pain will remain at comfortable level  during care  within
_____ period of time 
Patient will receive optimal level of pain and/or symptom management on
short-term basis 
Other: _____________________________________________________
Progress Toward Goals/Outcomes:

Pain Interventions:  FR 
Assess: Pain status 
Assess: Response to medications 
Assess  Perform  Instruct: Non-Pharmacological pain
control measures, e.g., relaxation, positioning, massage, etc. 
Other: ___________________________________________
General Inpatient Care Interventions:  FR 
Assess: Need for inpatient care for pain/symptom control 
Instruct: Patient/Caregiver regarding inpatient care 
Arrange transfer to inpatient facility per physician order 
Other: ___________________________________________

C   

RC RS 
 
 


N    

C     


RC RS 
 
 
 
 

N    

Comments:

Comments:
C = Problem has already been Identified
Form # HC8016-N

(Rev. 02/14)

INTERVENTIONS: Current/RECurred/RESolved/New:
RC = Problem has occurred after being resolved
N = Implement goals/outcome and interventions from IDG care plan

WHITE - Patient’s Chart

YELLOW - IDG File

PINK - Facility

Page 1 of 3

Patient’s Chart YELLOW . SEPARATE INTO THREE FORMS BETWEEN PAGES 1. infection to include: ______     _________________________________________________________________  Other: _________________________________________________      Provide appropriate air mattress Comments: CARDIO/RESPIRATORY STATUS Goals/Outcomes:  Patient/Caregiver will receive optimal teaching and support as cardiac and pulmonary functions change during care  Patient/Caregiver will demonstrate proper and safe use of oxygen set-up  Patient/Caregiver will verbalize understanding of medications and treatments  during care  within ____ period of time © 2006 MED-PASS.continued on next page INTERVENTIONS: Current/RECurred/RESolved/New: C = Problem has already been Identified Form # HC8016-N RC = Problem has occurred after being resolved WHITE . side   effects and response  Assess  Perform  Instruct: Skin breakdown and prevention    Other: ____________________________________________   Impaired Swallowing Interventions:  FR  Assess: Patient’s swallowing ability  Assess  Perform  Instruct: Medication administration. Last) ID# INTEGUMENTARY STATUS Goals/Outcomes:  Skin Integrity will be maintained  during care  within ___ period of time  Other: _______________________________________________________ Progress Toward Goals/Outcomes: Integumentary Interventions:  FR C RC RS N  Assess  Instruct: Skin breakdown and prevention     Assess  Perform  Instruct: Wound care as follows: ___________     _________________________________________________________________  Assess  Perform  Instruct: Stoma care as follows: ___________     _________________________________________________________________  Assess  Perform  Instruct: Incisional care as follows: _________     _________________________________________________________________  Assess  Instruct: s/s of complications.Indicates Facility is responsible for □ performing the respective function Patient Name (First. hydration and activity    Assess  Perform  Instruct: Fecal impaction and disimpact PRN      Assess  Perform  Instruct: Bowel regimen per physician   order and effectiveness  Assess  Perform  Instruct: Ostomy care to include: ______   ______________________________________________________________    Assess  Perform  Instruct: S/S enema PRN constipation  Assess  Perform  Instruct: S/S Fleet enema PRN constipation      Assess  Perform  Instruct: Medication administration.BEFORE WRITING ON THIS FORM.Facility Page 2 of 3 . Inc.IDG File N = Implement goals/outcome and interventions from IDG care plan PINK . MI. and patient/caregiver understands risk  during care within ____ period of time. fluid retention and dehydration  Assess  Instruct: s/s of infection  Other: __________________________________________ C RC RS N                C      RC RS      N     To order forms call: 800-438-8884 Comments: RENAL/GENITOURINARY STATUS Goals/Outcomes:  Skin will be maintained at optimal level  during care  within ____ period of time  Patient will be free of urinary tract infection  during care  within _____ period of time  Other: _____________________________________________________ Progress Toward Goals/Outcomes: Renal/Genitourinary Interventions:  FR  Assess: Urinary status  Assess  Instruct: Skin breakdown and prevention  Assess  Perform  Instruct: Condom catheter application and use  Assess  Perform  Instruct: Foley catheter ______ Fr _______ mL balloon  Assess  Perform  Instruct: Foley irrigation: ___________  Assess  Perform  Instruct: Solution ______________ mL _______ frequency ______  Assess  Perform  Instruct: Suprapubic catheter care: size _______  Assess  Perform  Instruct: Catheter care-frequency ____  Assess  Perform  Instruct: Catheter change q _________ with ___________________Fr _______ mL balloon catheter  Other: ___________________________________________ Review Date GASTROINTESTINAL STATUS Goals/Outcomes:  Patient’s nausea/vomiting will be controlled within ____ period of time  Promote optimal nutrition/hydration  during care  within _____ period of time  Patient/Caregiver will demonstrate ability to manage bowel routine within ____ period of time  Patient will maintain optimal swallowing. side   effects and response    Assess  Instruct: Nutritional changes and needs related to terminal illness    Assess  Instruct: Risk of aspiration  Assess  Perform  Instruct: Parenteral nutrition and the   care/use of equipment to include: ___________________________________ _____________________________________________________________ _  Assess  Perform  Instruct: Enteral nutrition and the care/   use of equipment to include: ______________________________________ _____________________________________________________________  Assess  Perform  Instruct: Gastrostomy Tube (specify):   __________________________________________________  Assess  Perform  Instruct: NG Tube (specify): __________      Assess  Perform  Instruct: J Tube (specify): ____________      Perform  Instruct: Change feeding tube__________________     using size ___________ q ________  Other:_____________________________________________     Bowel Interventions:  FR C RC RS N  Assess: Bowel status    Assess  Perform  Instruct: Nutrition. Progress Toward Goals/Outcomes: Respiratory Interventions:  FR  Assess: Respiratory status  Assess  Perform  Instruct: Proper and safe use of O2 administration at ______ liters/min via _________________. Hours of use ________  Assess  Instruct: Response to medications and treatment  Assess  Perform  Instruct: Nebulizer inhalation treatment with: ___________________________  Assess  Perform  Instruct: Suctioning technique  Assess  Perform  Instruct: Trach care  Assess  Perform  Instruct: Pulse Oximetry PRN for respiratory assessment  Other: __________________________________________ Cardiovascular Interventions:  Assess: Cardiovascular status  Assess  Instruct: Edema. 2. AND 3 HOSPICE IDG MEETING / CARE PLAN UPDATE ✓FR . per physician’s order  Other: ____________________________________________ C RC RS N         Comments: C RC RS    N                  PYSCHOLOGICAL / MENTAL /EMOTIONAL STATUS Goals/Outcomes:  Caregiver will demonstrate ability to cope with patient’s altered mental status within ____ period of time  Patient will be maintained in safe environment  during care  within ____ period of time  Patient’s agitation will be controlled to a manageable level  within ____ period of time  Patient will achieve optimal sleep/rest  during care  within ____ period of time  Patient will demonstrate or report a decrease in anxiety level  during care  within ____ period of time Progress Toward Goals/Outcomes: Comments: Pyschological/Mental/Emotional Status . Progress Toward Goals/Outcomes: GI Interventions:  FR C RC RS N  Assess: Nausea/Vomiting    Assess  Perform  Instruct: Medication administration. side effects and response  Assess  Perform  Instruct: Alter diet as patient’s condition deteriorates.

Last) ID# PYSCHOLOGICAL/MENTAL /EMOTIONAL STATUS (continued) Psychological Interventions:  FR C RC RS  Assess  Instruct: Level of consciousness/orientation    Assess  Perform  Instruct: Safety measures to prevent injury     Assess  Instruct: Current medications/potential side effects   causing alteration in mental status  Assess  Instruct: Causes. urinary retention. Inc. Progress Toward Goals/Outcomes: C Medication Interventions:  FR  Perform: Patient’s medications will be reviewed   Perform: Reorder of medications from pharmacy will be documented   Assess  Perform  Instruct: Discontinued medications will be  discarded per policy  Assess  Perform: Report to physician and IDG any medication  discrepancies If misuse or diversion is suspected:   Perform: Maintain medication in a lock box  Assess  Perform: Count medications every nursing visit  Other: _________________________________________________  High Tech/Special Procedures Interventions:  FR  Assess  Perform  Instruct: Administration of ________________  (IV medication) in ____________ (solution) to run at _______ mL/hr via ________________________ (Pump/Gravity)  Assess  Perform  Instruct: Flush IV/PICC/Midline with 5-10mL  of NS before and after antibiotic infusion.g.    constipation etc.  q ________ or q ________ days and PRN for s/s of infiltration/infection  Assess  Perform  Instruct: s/s of infiltration and emergency procedures   Other: _______________________________________________________  RC RS       N                      Equipment Interventions: C RC RS N  Assess  Perform  Instruct: Use of equipment     Other: __________________________________________     Comments: OTHER Progress Toward Goals/Outcomes: Interventions: □ FR  ______________________________________________  ______________________________________________  ______________________________________________       Date Medical Director Signature Date Form # HC8016-N To order forms call: N    OTHER ___________________________________________________ Progress Toward Goals/Outcomes:                ORDERS  SN Visit Frequency: ________ and ________ PRN for changes in status within ________ period of time  HHA Visit Frequency: __________ to assist w/personal care/ADLs/light house keeping as needed within ________ period of time  Physical Therapy Visit Frequency: ______________ to consult.Patient’s Chart YELLOW . pain.IDG File Social Worker Signature Date Team Member Signature Date PINK . evaluate and treat within ________ period of time  Occupational Therapy Visit Frequency: __________ to consult.Indicates Facility is responsible for □ performing the respective function Patient Name (First.  Assess  Perform  Instruct: Counseling    Assess  Perform  Instruct: Grief management  Other: ____________________________________________    Sleep Interventions:  FR C RC RS  Assess  Instruct: Causes of interruptions in sleep    Assess  Perform  Instruct: Medication administration.BEFORE WRITING ON THIS FORM. evaluate and treat within ________ period of time RN Signature RC RS       Goals/Outcomes:  _________________________________________________________  _________________________________________________________  _________________________________________________________ Interventions: □ FR  ______________________________________________  ______________________________________________  ______________________________________________ C    RC RS       N    Comments: Comments: C = Problem has already been Identified C    Comments:       ___________________________________________________ Goals/Outcomes:  _________________________________________________________  _________________________________________________________  _________________________________________________________  SW to evaluate and assess for needs ______ times per ______ and ______ PRN for counseling needs within ______ period of time  Dietary counseling PRN within ________ period of time  Volunteer for respite PRN within ________ period of time  SCC visit frequency _________ and PRN for spiritual support within ________ period of time  Copy sent to attending Physician INTERVENTIONS: Current/RECurred/RESolved/New: RC = Problem has occurred after being resolved N = Implement goals/outcome and interventions from IDG care plan Spiritual Care Coordinator Signature Date Volunteer Coordinator Signature Date Bereavement Coordinator Signature Date WHITE . e.Facility Page 3 of 3 .. MI. AND 3 HOSPICE IDG MEETING / CARE PLAN UPDATE ✓FR . SEPARATE INTO THREE FORMS BETWEEN PAGES 1. infection. evaluate and treat within ________ period of time  Speech Therapy Visit Frequency: _______________ to consult. 2. side   effects and response  Other: ____________________________________________    N    SPIRITUAL NEED STATUS Goals/Outcomes:  Spiritual needs will be met as determined by patient/caregiver  during care  within ____ period of time  Other: ______________________________________________________ Progress Toward Goals/Outcomes:    N    Comments: MEDICATIONS Goals/Outcomes:  Patient will receive prescribed medications at correct times (see Medication Profile)  Patient/Caregiver safely administers drugs and biologicals during care  Other: ___________________________________________________________ Review Date Spiritual Need Intervention:  FR  Assess  Instruct: Spiritual needs of the patient and caregiver  Assess: Current clergy support  Assess: Need for spiritual counselor to provide spiritual support  Other: ____________________________________________ C     RC RS         N     Comments: EQUIPMENT Goals/Outcomes:  Patient/Caregiver will receive equipment and demonstrate use at time of equipment set-up  Other: ____________________________________________________ Progress Toward Goals/Outcomes: 800-438-8884 © 2006 MED-PASS. Follow with 3-5mL Heparin _____ units/mL flush  Assess  Perform  Instruct: Change _________________ dressing  q _________ and PRN using sterile technique with alcohol/betadine  Assess  Perform  Instruct: Change injection cap q ___________  and PRN  Assess  Perform  Instruct: Flush __________________________  catheter with ____________________________________________  Assess  Perform  Instruct: Change Huber needle q __________ and  PRN using sterile technique  Assess  Perform  Instruct: Access port q _______ and PRN to flush  with _________________________________________________________  Assess  Perform  Instruct: Pump/Equipment (specify): ____________  ______________________________________________________________  Assess  Perform  Instruct: Equipment use/Safety   Assess  Perform  Instruct: Start Peripheral IV and maintain site.