Documenting Functional Findings & Symptoms In Hospice


This article will provide guidance on documenting functional findings and signs & symptoms in hospice patients.

Diminished functional status may be documented by either:

  1. Karnofsky Performance Scale of less than or equal to 50% or
  2. Dependence in at least three of the six activities of daily living including:
    • Bathing — to what extent does patient require assistance?
    • Dressing — what exactly can the patients do on their own?
    • Feeding — is the patient able to participate in feeding at all? If so, to what extent — drinking, eating finger foods, etc.?
    • Transfers — can the patient transfer from bed to chair, etc? How much assistance is required?
    • Continence of urine and stool
    • Ability to ambulate independently to bathroom

According to The Illinois Determination of Need Functional Assessment Instrument their ongoing ability to attend to self-care needs such as using the telephone and other household items as well as the ability to be alone can be included in functionality.

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Documentation Tips

Functional decline can be a determinant of disease progression regardless of diagnosis. Functional decline should be recent, meaning not occurring over a period of 10 years, for example.

Document all signs and symptoms including onset and change in status over time. For instance, what was the patient able to do on last visit that he/she is unable to do today?

“Last week patient was able to wash hands and face but is now requiring assistance”.

Collaborate with psychosocial and spiritual professionals to confirm that symptoms are managed with the most effective combination of non pharmacological and pharmacological interventions.

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