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 patients 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 patients 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 patients 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 patients 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:
 Patients 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 - Patients Chart

YELLOW - IDG File

PINK - Facility

Page 1 of 3

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)

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, 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, Inc.

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, 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:
 Patients 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, and patient/caregiver understands
risk  during care within ____ period of time.
Progress Toward Goals/Outcomes:

GI Interventions:  FR
C RC RS N
 Assess: Nausea/Vomiting
 
 Assess  Perform  Instruct: Medication administration, 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, 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, side
 
effects and response
 Assess  Perform  Instruct: Skin breakdown and prevention
 
 Other: ____________________________________________
 
Impaired Swallowing Interventions:  FR
 Assess: Patients swallowing ability
 Assess  Perform  Instruct: Medication administration, side
effects and response
 Assess  Perform  Instruct: Alter diet as patients condition
deteriorates, per physicians order
 Other: ____________________________________________

C RC RS N
 
 
 
 

Comments:

C RC RS




N




 
 
 
 
 
 
 

PYSCHOLOGICAL / MENTAL /EMOTIONAL STATUS

Goals/Outcomes:
 Caregiver will demonstrate ability to cope with patients altered mental
status within ____ period of time
 Patient will be maintained in safe environment  during care  within
____ period of time
 Patients 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 - 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 - Patients Chart

YELLOW - IDG File

N = Implement goals/outcome and interventions from IDG care plan

PINK - Facility

Page 2 of 3

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)

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, e.g., infection, pain, urinary retention,   
constipation etc.
 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, 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, Inc.

Progress Toward Goals/Outcomes:

C
Medication Interventions:  FR
 Perform: Patients 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. 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,

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, evaluate and treat
within ________ period of time
 Occupational Therapy Visit Frequency: __________ to consult, evaluate and treat
within ________ period of time
 Speech Therapy Visit Frequency: _______________ to consult, 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 - Patients Chart

YELLOW - IDG File

Social Worker Signature

Date

Team Member Signature

Date

PINK - Facility

Page 3 of 3