Patient Name: MR #: Date: Objective documentation is required to support hospice admission. This worksheet is intended to gather information on both the severity and trajectory of the patient s condition from the medical record and admission assessment to confirm admission criteria is met and to determine primary diagnosis and prognosis group. 1. List all pertinent diagnoses found in the medical record. 2. Complete form. 3. Return to this page and designate each diagnosis appropriately following assessment and collaboration with the attending physician/and medical director. Only 1 Diagnosis is marked as primary (first on claim). Multiple diagnoses may be directly related to primary diagnosis or indirectly related but equally affecting prognosis. All other diagnoses, not determined as affecting prognosis, will be considered unrelated. DIAGNOSIS PER MEDICAL RECORD ICD 10 CODE ACTIVE SYMPTOMS YES NO PRIMARY RELATED TO UNRELATED DIAGNOSIS PROGNOSIS COMORBIDITY Information received from physician/facility/family, about current condition that has resulted in a referral to hospice. Give a general review of the past 6 months. (Directions: Check all that Apply) PART I: Decline in Clinical Status Guidelines: Increasing emergency room visits, hospitalizations/physician s visits related to diagnosis. Explain: Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract. Explain: Progressive Nutritional Decline: (Not related to reversible causes such as depression or diuretics) Weight Loss or Weight Gain Most Recent/Admit Weight: Date of Weight: Prior Weight: 3 months: 6 months: % of Change: Factors Related to Weight Change: Decreasing Anthropomorphic Measurement Rt. Arm: Lt. Arm: Date of Measure: Abdominal Girth: Thigh (Rt. or Lt.): Decreasing Albumin or Cholesterol Levels Albumin Level: Date: Past Level: Pre-Albumin Level: Date: Past Level: Cholesterol Level: Date: Past Level: Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by: Decreasing food portions or consumption. Has not responded to enteral nutritional support, despite adequate caloric intake due to intolerance or other complications supporting not reasonable to expect prolonged life. Other intake pattern issues: Form 10P 2/ BRIGGS, Des Moines, IA Unauthorized copying or use violates copyright law. PRINTED IN U.S.A. Page 1 of 6
BMI score on admission: ( is considered at risk) Height (in) BMI 58 59 60 61 62 63 64 65 66 67 Wgt. (lbs.) 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 100 105 110 1 1 1 0 5 0 29 5 30 29 0 31 30 29 5 32 31 30 29 0 34 32 31 30 29 5 35 33 32 31 30 29 0 36 34 33 32 31 30 29 5 37 35 34 33 32 31 30 29 0 38 36 35 34 33 32 31 30 29 5 39 37 36 35 34 33 32 31 30 29 0 40 38 37 36 35 34 33 32 31 30 5 41 39 38 37 36 35 34 33 32 31 0 42 40 39 38 37 36 34 33 32 31 Progressively Worsening Signs and Symptoms: General Symptoms: Dyspnea with increasing respiratory rate. Oxygen usage: Pulse Ox level at rest: Pulse Ox level after exertion: Cough, intractable or other: Nausea/vomiting poorly responsive to treatment: Diarrhea, intractable: Pain requiring increasing doses of major analgesics with long-term usage. Describe: Other: General Signs: Decline in systolic blood pressure to below 90 or progressive postural hypotension: Ascites or another progressive edema: Venous, arterial or lymphatic obstruction due to local progression or metastatic disease. Pleural/pericardial effusion: Progressive weakness (Give objective description): Change in level of consciousness: Laboratory Results: (When available lab testing is not required to establish hospice eligibility.) Decreasing po2 or increasing pco2: Increasing calcium, creatinine, BUN or liver function studies: Increasing tumor markers (e.g. CEA, PSA): Progressive changes in sodium/potassium level: Other: *** Obtain copies of all available dietary records, laboratory records, radiology records, radiology reports, etc. *** Page 2 of 6 68 5'8" 29 30 30 69 5'9" 29 30 70 5'10" 29 71 5'11" 72 6'0" 73 6'1" 74 6'2" 75 6'3" 76 6'4" 12
PART II: Non-Disease Specific Baseline Guidelines: (both must be met) 1. Palliative Performance Scale (PPS)* Admission Score: Performance Score of <70% in general and less than <40-50% for some disease specific guidelines. PPS Ambulation Activity & Evidence of Level Disease Progression Self-Care Intake Level Conscious Level 80% Full Normal Activity with Effort Full Normal Full 70% Reduced Unable to work normal job/ Full Normal or Reduced Full Significant evidence of disease 60% Reduced Unable to do hobby/housework Occasional Assistance Same Full or Confused 50% Mainly Sit/Lie Unable to do any work Considerable Assistance Same Full or Confused 40% Mainly in Bed Unable to do most activities Mainly Assisted Same Full or Drowsy +/- Confusion 30% Totally in Bed Unable to do any activities Total Care Reduced Same % Totally in Bed Unable to do any activities Total Care Minimal/Sips Same 10% Totally in Bed Unable to do any activities Total Care Mouth Care Drowsy or Coma 0% Death 2. Dependance on assistance for two or more activities of daily living (ADLs) Feeding Transfer Ambulation Bathing Continence Dressing Karnofsky Performance Status Scale* Admission Score: The lower the Karnofsky score, the worse the survival for most serious illnesses. Able to carry on normal activity and to work; no special care needed. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. Unable to care of self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 100 Normal no complaints; no evidence of disease. 90 Able to carry on normal activity; minor signs or symptoms of disease. 80 Normal activity with effort; some signs or symptoms of disease. 70 Cares for self; unable to carry on normal activity or to do active work. 60 Requires occasional assistance, but is able to care for most of his personal needs. 50 Requires considerable assistance and frequent medical care. 40 Disabled; requires special care and assistance. 30 Severely disabled; hospital admission is indicated although death not imminent. Very sick; hospital admission necessary; active supportive treatment necessary. 10 Moribund; fatal processes progressing rapidly. 0 Dead Disease Specific Guidelines: Note: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part I and Part II. Documentation should paint a picture for the reviewer to clearly see why the patient is appropriate for hospice care and the level of care provided, i.e., routine home, continuous home, inpatient respite or general inpatient. The records should include observations and data, not merely conclusions. During the initial assessment for hospice appropriateness, complete the disease specific guideline for each pertinent diagnosis identified in medical records. CANCER Type and Location of Cancer Diagnosis Identified in Medical Record: Note: Certain cancers with poor prognoses (e.g. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. Class III or IV per medical record Distant Metastasis: Progressed from earlier stage with: Continuous decline despite treatment Patient declines further disease directed therapy Page 3 of 6
DEMENTIA, END STAGE Type of Dementia Identified in Medical Record: (This guide is for Alzheimer s Type of Dementia, not multi-focus Dementia.) 1. Should show all the following characteristics: Stage 7 FAST Unable to bathe without assistance Unable to ambulate without assistance Urinary and fecal incontinence Unable to dress without assistance No consistent meaningful communication Alzheimer s Dementia Functional Decline* FAST Classification Admission Score: FAST Scale Stage Characteristics 1. Normal Adult No functional decline. 2. Normal Older Adult Personal awareness of some functional decline. 3. Early Alzheimer s Noticeable deficits in demanding job situations. 4. Mild Alzheimer s Requires assistance in complicated tasks such as handling finances. 5. Moderate Alzheimer s Requires assistance in choosing proper attire. 6. Moderately Severe Alzheimer s Requires assistance dressing, bathing and toileting. Experiences urinary and fecal incontinence. 7. Severe Alzheimer s A. Ability to speak limited to six words D. Inability to sit without lateral support B. Ability to speak limited to single word E. Inability to smile C. Loss of ambulation F. Inability to hold head up 2. Should have life-threatening complication within past 12 months: Aspiration Pneumonia Pyelonephritis or other upper UTI or Septicemia Decubitus Ulcer, stage 3-4 Fever, recurrent after antibiotics 10% weight loss over prior 6 months or Albumin Level <2.5 gm/dl CARDIOVASCULAR DISEASE, END STAGE Cardiac Diagnoses in Medical Records: Patient must have #1 and either #2 or #3 present: 1. CHF with a NYHA Class IV Symptoms and has declined invasive treatments. The Stages of Heart Failure NYHA Classification Class Level at Admission: Class Patient Symptoms Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnea (shortness of breath). Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea. Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation or dyspnea. Class IV (Severe) Unable to carry out any physical activity without discomfort, such as; fatigue, dyspnea or angina. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased. 2. The patient: May have symptoms of congestive failure and/or angina at rest. CHF may be documented by Echo showing EF of Patient s EF: Date: Has an inability to carry out minimal physical activity without dyspnea or angina increasing. 3. Patient is optimally treated with: (Or they have a medical reason why they cannot be.) Diuretics: ACE inhibitors: Vasodilators: Nitrates: Other: PASP Level: Additional Supportive Documentation: (Supportive of Pulmonary Hypertension) Treatment resistant symptomatic supraventricular or ventricular arrhythmias: History of cardiac arrest or resuscitation History of unexplained syncope Brain embolism or secondary CVA of cardiac origin Concomitant HIV disease *Note: If no CHF: Other end-stage cardiac information to support end-stage must be clearly available in the medical record. Page 4 of 6
PULMONARY DISEASE, END STAGE Pulmonary Diagnoses in Medical Records: (1 and 2 should be present and 3-5 documented will lend support.) 1. Severe chronic lung disease as documented by disabling dyspnea at rest, poorly or unresponsive to bronchodilators resulting in decreased functional capacity, e.g., bed to chair existence, fatigue and cough. FEV1 after bronchodilator <30% of predicted. Patient %: Progression as evidenced by: Increasing visits to emergency room Hospitalization for pulmonary infections and/or respiratory failure Increased home physician visits Objectively documented with decrease in FEV 1 >40 ml/year 2. Hypoxemia at rest on room air, as evidenced with po2 55% or Oxygen saturation 88% or Hypercapnia with pco2 50 mmhg 3. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (Not secondary to left heart disease or valvulopathy Any Valve Disease.) 4. Unintentional weight loss >10% over prior 6 months 5. Resting Tachycardia >100 bpm Pulse at rest on admission: LIVER DISEASE, END STAGE Liver diagnoses in Medical Records: (Patients waiting for transplants can be admitted for service) (1 and 2 should be present and 3 documented will lend support.) 1. End stage liver disease demonstrated with PT prolonged more than 5 seconds or INR >1.5 and Serum albumin <2.5 2. One or more of the following conditions: Ascites, refractory to treatment or patient non-compliance Hepatorenal syndrome: (elevated creatinine and BUN with oliguria <400 cc per day and urine sodium <10 meq/l History of recurrent variceal bleeding despite intensive therapy 3. Additional supportive documentation may include: Progressive malnutrition Muscle wasting with reduced strength and endurance Continued active alcoholism (>80 gm ethanol/day) RENAL DISEASE, END STAGE History of spontaneous bacterial peritonitis Hepatic encephalopathy, refractory to treatment Hepatocellular Carcinoma Hepatitis B surface antigen positive Hepatitis C refractory to interferon treatment Renal Diagnoses in Medical Records: 1 and either 2 or 3 should be present. 1. Patient is not seeking dialysis/transplant or is discontinuing dialysis 2. Creatinine clearance is <10 cc/min (< cc/min for patient with diabetes) 3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for patient with diabetes) Other supportive documentation includes: Acute Renal Failure with: Mechanical Ventilation Immunosuppression/AIDS Malignancy in another organ Albumin <3.5 gm/dl Chronic lung disease Cachexia Advanced cardiac disease Platelet count <,000 Advanced liver disease Disseminated intravascular coagulation Sepsis GI bleeding Chronic Renal Failure with: Uremia (GFR < is typical) Pt. level: Oliguria of <400 cc/ hrs Intractable hyperkalemia of >7.0 not responsive to treatment Uremic pericarditis Hepatorenal syndrome Intractable fluid overload, not responding to treatment Page 5 of 6
STROKE & COMA, END STAGE Patients will be considered to be in the terminal stage of stroke or coma if they meet the following: PPS <40% Inability to maintain hydration Weight loss of 10% in 6 months or 7.5% in the last 3 months Serum albumin 2.5 Current history of pulmonary aspiration not respon sive to speech language pathology intervention Sequential calorie counts documenting inadequate caloric/fluid intake Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration. Comatose Patient with 3 of the following on the 3rd day: Abnormal brain stem response Doll s Eyes (no natural movement of eyes) Absent verbal responses Absent withdrawal response to pain Serum creatinine >1.5 gm/dl Documentation of the following factors, in the context of progressive clinical decline, within the past 12 months will support eligibility: Aspiration Pneumonia Date: Refractory stage 3-4 decubitus ulcers Upper urinary tract infection (pyelonephritis) Fever recurrent after antibiotics Sepsis Additional information about Diagnostic Imaging Factors can support poor prognosis after a stroke. ALS, END STAGE ALS must demonstrate either 1 or 2 below 1. Critically impaired breathing capacity with the following in the past 12 months: Significant dyspnea at rest Vital capacity less than 30% Patient declines artificial ventilation External ventilation may be used for comfort measures only 2. Rapid disease progression: Progressed to wheelchair or bed-bound Progressed to barely intelligible speech Progressed from normal to pureed diet Progressed from independent to assisted with all activities of daily living And critical nutritional impairment Oral intake of nutrients and fluids insufficient to sustain life Continuous weight loss Dehydration or hypovolemia Absence of artificial feeding methods sufficient to sustain life, but not for relieving hunger 3. In Addition: Life-threatening complications in the past 12 months: Recurrent aspiration pneumonia with or without tube feedings Upper urinary tract infection (pyelonephritis) Sepsis Recurrent fever after antibiotic therapy HIV Disease 1. CD4+ Count < cells/mcl or persistent viral load >100,000 copies/ml plus one of the following: CNS lymphoma Persistent body wasting (10% body mass) Mycobacterium avium complex (MAC) bacteremia, untreated or unresponsive Progressive multifocal leukoencephalopathy Systemic Lymphoma Visceral Kaposi Sarcoma, unresponsive Renal Failure in the absence of dialysis Crypotosporidium Infection Toxoplasmosis Additional supportive documentation: PPS score of 50% Chronic diarrhea for >1 year Active substance abuse >50 years old Absence of or resistance to drug therapy CHF, symptomatic at rest Advanced liver disease For other neurological diagnoses, not addressed in the disease specific guidelines, (such as Multiple Sclerosis, Parkinson s, Huntington s), describe any specific symptoms to support a <6 month predicted prognosis: Nurse Signature: Date: Page 6 of 6 HIV, END STAGE