Hospice SOAP Note Example: Complete Documentation Guide for End-of-Life Care

Hospice documentation carries emotional weight that other medical notes don't.

You're not documenting treatment plans aimed at cure or recovery—you're chronicling someone's final chapter while ensuring their comfort and dignity.

Yet hospice providers face intense documentation scrutiny.

Medicare audits hospice claims more aggressively than almost any other service, questioning medical necessity, reviewing symptom management, and examining whether patients truly meet eligibility criteria.

One poorly worded note can trigger recoupment demands for thousands of dollars, forcing families to repay benefits during their grief.

The providers I've worked with describe hospice documentation as emotionally draining and technically demanding—you're supporting grieving families while writing notes that justify every visit to Medicare reviewers who've never met your patient.

I built SOAP Notes Doctor to ease this burden, helping you create compliant documentation that protects patients and families while honoring the profound work you do.

Let me show you what effective hospice documentation looks like.

Why Hospice Documentation Requires a Different Approach

Hospice notes aren't like other medical documentation.

You're documenting decline, not improvement. You're managing symptoms, not curing disease. You're supporting families through grief, not celebrating recovery milestones.

This creates unique challenges:

Medicare requires evidence of terminal illness with life expectancy of six months or less if disease follows expected course. Your notes must demonstrate continued decline or disease progression.

Symptom management must be clearly documented to justify medications, supplies, and nursing visits. Vague descriptions like "patient comfortable" don't satisfy Medicare requirements.

Psychosocial and spiritual support for patients and families is part of the hospice benefit, but often gets inadequately documented despite consuming significant care time.

IDG (Interdisciplinary Group) coordination must be evident in your notes—showing collaboration with nurses, social workers, chaplains, and aides as a unified care team.

Recertification periods require documentation that the patient continues to meet hospice eligibility criteria, not that they're stable and doing well.

Your hospice notes need to paint a complete picture of end-of-life care while satisfying regulatory requirements that weren't written by people who do this work.

What Medicare Auditors Look for in Hospice Notes

After reviewing countless Medicare audit findings, I can tell you exactly what triggers recoupment demands:

Lack of decline documentation: If your notes make the patient sound stable or improving over multiple visits, auditors question continued eligibility.

Insufficient symptom detail: "Pain managed" doesn't demonstrate medical necessity. Auditors want specific pain scores, locations, breakthrough episodes, and interventions.

Missing functional status changes: Document ADL dependencies, mobility changes, weight loss, intake decline—objective markers of deterioration.

Inadequate caregiver support documentation: Family education, caregiver strain, and bereavement support are covered services but often go undocumented.

Weak terminal diagnosis justification: Your notes must clearly link symptoms and decline to the terminal diagnosis, not comorbid conditions.

The documentation standard isn't "Would another hospice provider think this is appropriate?" It's "Can we prove medical necessity to an auditor who's never met this patient?"

That's a much higher bar.

Example 1: Initial Hospice Evaluation, Cancer Diagnosis

Patient: 71-year-old female
Diagnosis: Stage IV pancreatic cancer with liver metastases
Visit Type: Initial hospice admission assessment
Location: Patient's home

S – Subjective:

Patient admitted to hospice today following oncology referral after declining further chemotherapy. Diagnosed with pancreatic cancer 14 months ago, initially treated with FOLFIRINOX chemotherapy. Recent CT shows disease progression with extensive liver involvement despite treatment. Patient and family state "we want to focus on comfort now, not more treatment that makes her sick." Reports worsening fatigue over past month, now spending most of day in recliner or bed. Appetite markedly decreased, eating only few bites at meals. Abdominal pain present, describes as constant dull ache rated 6/10, with sharp spikes to 8/10 after eating. Currently taking acetaminophen which provides minimal relief. Nausea intermittent, worse in mornings. Denies vomiting currently but had significant issues during last chemo cycle 3 weeks ago. Constipation problematic, no bowel movement in 4 days. Reports feeling weak, needs assistance to walk to bathroom. Daughter primary caregiver, appears overwhelmed but committed. Patient emotionally tearful, states "I'm ready, I just don't want to suffer."

O – Objective:

Vital Signs: BP 102/64, HR 94, RR 18, Temp 98.2°F, O2 sat 94% on room air, Weight 98 lbs (down from 135 lbs at diagnosis per daughter)
General: Cachectic female, jaundiced appearance, appears fatigued, speaking in soft voice
ECOG Performance Status: 3 (capable of limited self-care, confined to bed/chair greater than 50% of waking hours)
Palliative Performance Scale: 40% (mainly in bed, unable to do most activity, extensive disease)
Skin: Jaundiced, poor turgor indicating dehydration, no pressure injuries currently
Abdomen: Distended, firm, tender to palpation in epigastric and RUQ areas, liver edge palpable 6cm below costal margin
Extremities: Muscle wasting evident, peripheral edema 1+ bilateral ankles
Mental Status: Alert and oriented x3, appropriate responses, making eye contact, tearful affect
Pain Assessment: Reports pain 6/10 at rest in epigastric region, radiating to back, worse after eating
Functional Status: Dependent for transfers, bathing, dressing. Requires assistance to ambulate to bathroom with walker. Continent of bowel and bladder currently.

A – Assessment:

71-year-old female with terminal stage IV pancreatic adenocarcinoma with extensive hepatic metastases meeting hospice eligibility criteria. Prognosis 6 months or less based on disease progression despite treatment, declining performance status (ECOG 3, PPS 40%), significant weight loss (37 lbs/27% body weight), and worsening symptoms consistent with end-stage cancer. Patient demonstrates multiple indicators of decline including cachexia, weakness, decreased intake, and functional dependence. Pain currently inadequately controlled on over-the-counter medications alone. Constipation likely opioid-related from inadequate bowel regimen and decreased intake. Psychosocial needs significant for both patient and family caregiver dealing with transition to end-of-life care. Patient has clear understanding of terminal prognosis and has chosen comfort-focused care over continued disease-directed treatment.

P – Plan:

Symptom Management:

• Pain control: Initiated morphine sulfate immediate-release 15mg PO q4h scheduled, with 5mg PO q1h PRN for breakthrough pain. Educated patient and daughter on use, side effects, and breakthrough dosing. Emphasized that adequate pain control is priority.
• Constipation: Started senna 2 tabs daily and docusate 100mg BID. Discussed importance of bowel regimen with opioid use. Will add Miralax if no BM in 48 hours.
• Nausea: Prescribed ondansetron 4mg PO q8h PRN. Discussed small frequent meals, bland foods.

Hospice Services Initiated:

• RN to visit 3x weekly initially for symptom assessment and medication management
• HHA 5x weekly for personal care, bathing assistance
• Social worker to visit within 5 days for psychosocial assessment and caregiver support
• Chaplain referral offered, family declined at this time
• Volunteer services offered for respite, family considering
• DME ordered: hospital bed, bedside commode, oxygen concentrator for comfort PRN

Family Education and Support:

• Discussed disease trajectory and what to expect as disease progresses
• Provided information on signs of imminent death
• Reviewed 24/7 hospice nurse availability for urgent concerns
• Addressed daughter's caregiver concerns and need for respite
• Provided written materials on pain management, comfort care

IDG Communication:

• Case reviewed with medical director
• Care plan established with IDG team
• Follow-up visit scheduled in 3 days to assess pain control and symptom management

Patient and family verbalized understanding of hospice services, symptom management plan, and 24/7 availability. Daughter given hospice contact numbers. Will monitor closely for symptom control and medication titration needs.

---

Example 2: Routine Hospice Visit, Dementia Patient

Patient: 86-year-old male
Diagnosis: Advanced Alzheimer's dementia
Visit Type: Routine nursing visit, day 45 of hospice
Location: Skilled nursing facility

S – Subjective:

Per nursing staff report, patient has experienced continued decline over past 2 weeks. Now completely bedbound, no longer attempting to sit up or transfer. Eating has decreased further, accepting only few spoonfuls of pureed food and thickened liquids with extensive coaxing. Total intake approximately 25% of meals. Weight loss noted. Unable to communicate verbally—no words spoken in past week. Makes occasional sounds but non-meaningful. Staff reports patient appears comfortable most of time but occasionally grimaces during repositioning. No clear distress vocalizations. Sleep-wake cycle disrupted, dozing throughout day and night. Daughter visited yesterday, states father "doesn't seem to recognize anyone anymore." Staff note patient no longer tracks with eyes or responds to voice.

O – Objective:

Vital Signs: BP 94/58, HR 68, RR 16, Temp 97.8°F, Weight 112 lbs (down 6 lbs from admission weight 118 lbs)
General: Cachectic elderly male, lying in hospital bed, eyes closed but opens briefly to loud voice, no purposeful movement observed
FAST Scale: Stage 7e (unable to ambulate, unable to sit up, unable to smile, cannot hold head up)
Mental Status: Non-responsive to verbal stimuli, no eye contact, no recognition of examiner, no speech
Skin: Intact, no pressure injuries, good care evident, Stage 1 redness noted over sacrum with appropriate repositioning schedule in place
Oral: Mucous membranes slightly dry, mouth care being provided by staff
Respiratory: Clear lung sounds bilaterally, no distress, regular unlabored breathing
Cardiovascular: Weak peripheral pulses, cool extremities, no edema
Nutrition: Intake logs show declining oral intake: averaging less than 300 calories daily over past week
Functional Status: Completely dependent for all ADLs, bedbound, requires total care, contractures developing in bilateral upper extremities

A – Assessment:

86-year-old male with advanced Alzheimer's dementia (FAST Stage 7e) showing continued decline consistent with end-stage dementia trajectory. Patient meets continued hospice eligibility based on progression of dementia to FAST stage 7 with complications: inability to ambulate, inability to sit up independently, speech limited to single words or less, inability to smile, inability to hold head up. Additional supporting factors include significant weight loss (5% over 6 weeks), declining oral intake (less than 500 calories daily), loss of meaningful communication, and progression to bedbound status. Patient comfortable on current care plan without signs of uncontrolled pain or distress. Family demonstrates appropriate understanding of disease progression and comfort-focused approach.

P – Plan:

Continued Comfort Care:

• Pain/comfort monitoring ongoing via behavioral pain assessment (grimacing, guarding, vocalizations). No current indicators of uncontrolled pain.
• Continue acetaminophen 650mg suppository q8h scheduled for baseline comfort
• Morphine concentrate 2.5mg sublingual PRN available for respiratory distress or signs of pain, staff educated on use

Nutrition and Hydration:

• Continue hand-feeding with patient-preferred foods in pureed form
• No forced feeding, respecting patient's declining intake as part of natural disease progression
• Mouth care with swabs QID to maintain comfort

Skin Care:

• Turning/repositioning schedule q2h maintained
• Stage 1 pressure area over sacrum with barrier cream, monitoring for progression
• Continue current prevention measures

Family Support:

• Social worker to contact daughter this week for check-in
• Discussed signs of further decline and what to expect
• Reinforced that declining intake is expected part of disease process, not suffering

IDG Coordination:

• Case reviewed at IDG meeting this week
• All team members aware of continued decline
• Plan maintained, no changes needed at this time

Patient continues to meet hospice criteria with ongoing decline. Will continue routine visits as scheduled. Staff has 24/7 hospice contact number for any changes or concerns.

---

Example 3: Crisis Visit, Actively Dying Patient

Patient: 58-year-old male
Diagnosis: End-stage COPD with cor pulmonale
Visit Type: Crisis/unscheduled nursing visit
Location: Patient's home

S – Subjective:

Called to home by family for increased respiratory distress. Wife reports patient's breathing became "much worse" overnight. States he's been restless, unable to get comfortable, breathing rapidly. Not sleeping. Appears more confused than usual this morning, didn't recognize daughter. Has not eaten or taken oral medications since yesterday evening. Wife tearful, states "Is this it? Is he dying?" Per hospice records, patient has been on service for 4 months with progressive respiratory decline. Recent hospitalizations prior to hospice for respiratory failure requiring BiPAP.

O – Objective:

Vital Signs: BP 88/54 (baseline 110-120/60-70), HR 110, RR 28 labored, Temp 97.2°F, O2 sat 84% on 4L oxygen via nasal cannula (baseline 88-92%)
General: Cachectic male in moderate respiratory distress, appears drowsy but restless, diaphoretic
Mental Status: Lethargic, minimally responsive to voice, confused when aroused, not following commands consistently
Respiratory: Tachypneic with accessory muscle use, diminished breath sounds throughout, coarse crackles bilateral bases, prolonged expiratory phase. Pursed lip breathing. Unable to complete full sentences.
Cardiovascular: Tachycardic, irregular rhythm, weak peripheral pulses, cool mottled extremities, peripheral cyanosis noted
Extremities: 3+ pitting edema bilateral lower extremities to knees (increased from prior), mottling noted on lower legs and feet
Skin: Cool, diaphoretic, poor perfusion evident

A – Assessment:

58-year-old male with end-stage COPD experiencing acute decompensation with signs consistent with actively dying: declining mental status, increased work of breathing despite oxygen, hemodynamic instability (hypotension, tachycardia), decreased perfusion (mottling, cool extremities), and inability to take oral intake or medications. Patient transitioning to active dying phase. Family present and distressed, requiring crisis-level support and education regarding dying process.

P – Plan:

Immediate Symptom Management:

• Discontinued oral medications given inability to swallow safely
• Initiated morphine sulfate 5mg subcutaneously for respiratory distress and air hunger, can repeat q1h as needed
• Administered initial dose of morphine 5mg SQ, patient appears less restless within 15 minutes
• Increased oxygen to 6L for comfort (not for oxygenation goals)
• Positioned patient in high Fowler's to ease breathing
• Started scopolamine patch for secretion management

Family Support and Education:

• Explained to wife and daughter that patient showing signs of active dying process, likely hours to days
• Discussed what to expect: further decline in responsiveness, changing breathing patterns (Cheyne-Stokes), decreased circulation (mottling), cessation of intake
• Reassured that patient appears comfortable with current symptom management
• Encouraged family presence, talking to patient, touch
• Explained that hearing is last sense to go, encouraged speaking to him

Crisis Level Care:

• Initiated continuous care level of hospice (crisis care) due to acute symptom management needs
• RN to remain in home for next 4 hours to stabilize symptoms and support family
• Will reassess symptoms and family needs to determine if continuous care should be extended
• Provided written information on active dying process

IDG Communication:

• Notified hospice medical director of status change
• On-call physician aware and available for medication orders if needed
• Social worker and chaplain contacted, will follow up with family

Remained in home for 4 hours. Patient's respiratory distress improved with morphine administration (3 additional doses given). Family supported through initial crisis. Patient more comfortable though remains lethargic. Continuous care level maintained, second nurse scheduled for overnight shift. Family educated on medication administration and when to call. Will continue close monitoring and family support through this transition.

---

Essential Components Every Hospice SOAP Note Needs

Based on Medicare compliance requirements and audit patterns, every hospice note should include:

Terminal Diagnosis Clearly Stated

Document the primary terminal diagnosis and how current symptoms relate to disease progression. Link everything back to terminal condition.

Functional Decline Documentation

Use objective measures: PPS scores, FAST stages for dementia, ECOG scores for cancer. Document specific ADL dependencies and changes from previous visits.

Symptom Detail with Interventions

Never write "pain controlled" or "comfortable" alone. Document pain scores, locations, interventions used, and response to treatment.

Weight and Intake Tracking

Document weight, appetite changes, intake percentages. These are objective markers Medicare looks for in terminal illness progression.

IDG Coordination Evidence

Show collaboration with the interdisciplinary team. Reference social worker visits, chaplain involvement, aide reports.

Family Education and Support

Document what you taught families, their understanding, and caregiver burden assessment. This justifies visits and services.

Continued Eligibility Support

Each recertification period requires documentation that patient continues to decline or shows disease progression consistent with terminal prognosis.

Common Documentation Pitfalls That Trigger Medicare Audits

After analyzing Medicare audit patterns, these documentation mistakes most frequently trigger recoupment:

"Patient stable and comfortable" appears in multiple consecutive notes → Auditors question terminal status if patient seems stable for weeks.

Vague symptom descriptions without specific details → "Some pain" or "breathing okay" don't justify medication costs or nursing visits.

No documented decline over recertification period → If notes don't show progression, auditors question continued eligibility.

Missing visit frequency justification → Each visit should document what assessment or intervention occurred that required skilled nursing.

Inadequate terminal diagnosis connection → Symptoms must clearly relate to the terminal condition, not comorbidities.

Lack of functional status changes → Without documented ADL changes or PPS/FAST scores, there's no objective decline evidence.

Documentation Strategies That Protect Against Audits

Here's what works to create audit-resistant hospice documentation:

Use standardized scales consistently: PPS, FAST, ECOG scores provide objective benchmarks that Medicare auditors recognize.

Compare to baseline and previous visits: "Weight 98 lbs today, down from admission weight of 118 lbs" tells a story of decline.

Document specific symptom assessments: "Pain rated 4/10 in right hip, relieved to 1/10 after morphine 5mg" justifies skilled nursing and medications.

Connect symptoms to terminal diagnosis: "Dyspnea increasing due to progression of lung cancer" links symptom to terminal condition.

Record family/caregiver observations: "Wife reports patient sleeping more, eating less this week" provides longitudinal decline data.

Document what changed: Each visit note should identify what's different from last visit, even if subtle.

Include barriers to improvement: "Patient continues to decline despite optimal symptom management" reinforces terminal trajectory.

How SOAP Notes Doctor Supports Hospice Documentation

When you use SOAP Notes Doctor for hospice visits, the system:

• Incorporates Medicare-required elements automatically
• Includes appropriate performance scales and functional assessments
• Documents decline trajectories that support continued eligibility
• Uses compliance-friendly language throughout
• Links symptoms explicitly to terminal diagnoses
• Includes family education and IDG coordination documentation
• Structures crisis visit notes appropriately

You record the visit details—symptoms, interventions, family interactions—and the system formats everything to meet Medicare requirements while maintaining the dignity and humanity of end-of-life care documentation.

Try it at soapnotes.doctor and see how it supports your hospice documentation needs.

Final Thoughts on Hospice Documentation

Hospice documentation requires balancing profound human moments with bureaucratic compliance requirements.

You're sitting with families during the hardest days of their lives, providing comfort to dying patients, and somehow you need to document it all in ways that satisfy Medicare auditors who've never met your patients.

That burden is real, and it's heavy.

Good hospice documentation protects patients and families from financial harm while honoring the sacred work you do.

It demonstrates that patients genuinely need hospice services, that symptoms require skilled management, that families need support navigating grief and loss.

Whether you write notes manually or use SOAP Notes Doctor, focus on objective decline markers, specific symptom details, functional status changes, and clear connection to terminal diagnosis.

These elements create documentation that withstands scrutiny while capturing the reality of end-of-life care.

Your patients and families deserve both excellent care and protection from audit recoupments during their most vulnerable time.

---

Ready to streamline your hospice documentation?
Visit soapnotes.doctor and create Medicare-compliant hospice notes that honor your patients' final journey.