Cracking the Code: 4 Steps to Better Nursing Notes

As a hospice nurse, you understand the importance of accurate, detailed documentation. However, composing hospice narrative notes can be challenging and leave you feeling frustrated. What if I told you there’s a simple way to compose nursing notes? Well, there is! By following these four simple steps, you can enhance the quality and effectiveness of your documentation without sacrificing your precious time.

Let’s delve into this process together.

Last year, I was challenged to deliver a 20-minute training session to help hospice nurses compose narrative notes in a way they could implement quickly.

The challenge was to do this in a way that ensured compliance with hospice eligibility requirements.

No problem! Check it out below!

I’m considering making this a FREE mini-course. If you’re interested hit the REPLY button and let me know if you’d be interested!

The Importance of Narrative Notes

Ever wondered why your hospice notes matter so much? Here’s the deal. Your nursing notes are the hidden gems that support the patient’s terminal diagnosis and ongoing hospice eligibility.

Your charting is not just paperwork! It’s the backbone of the care plan.

It all begins with the patient’s admission to hospice and your comprehensive admission assessment and ends when your patient passes away.

First of all, hospice nursing notes contain technical information that is obtained from various sources including the patient, the medical record, and the patient’s family or caregivers.

Now, you’ve probably heard the term “paint the picture,” right?

Well, that’s exactly what the goal is when you compose a nursing narrative note.

Unlocking the Hospice Narrative Note Maze:

As a fellow hospice nurse, I get it. Hospice notes are long and complicated.

It doesn’t have to be.

Here are the four basic steps I came up with to help you build better notes.

PRO-TIP- Write your nursing narrative as if it is a stand-alone document. If a reviewer were to look at your note, would they be able to tell what is going on with the patient and how they are declining?

Step #1: Gather Information

Your documentation is meant to tell the patient’s story. To do this, you must be a detective and look for details and clues that answer these questions: Why Hospice? Why Now?

 Where to Find Information

• Examine the patient’s EMR
• Review recent hospitalizations
• Patient interview and assessment
• Families and caregivers
• Past and current treatments
• Anywhere you can!!

Hospice Assessment Scales

• Palliative Performance Scale
• Karnofsky Scale
• NYHA
• FAST

Additional Assessment Information

• Objective vs. Subjective
• Hospice Scales
• ADLs/IADLs
• Worsening wounds
• Frequent, recurring infections i.e. pneumonia, UTIs
• any hospitalization and/or ER visits
• Recent falls (injury i.e. broken hip)
• Change in mentation (level of consciousness)
• Ascites
• Pleural effusions (malignant)
• Edema related to terminal illness (CHF)
• Labs-albumin, tumor markers, & liver function

Step #2 Use Your Senses to Build Hospice Narrative Notes

• Save

This is my favorite step because it works for every patient and diagnosis! As a bonus, it’s the best tool you have when you’re building your nursing notes for IDG and recertifications.

Ask yourself these questions:

1. What do you SEE?
2. What do you HEAR?
3. What do you SMELL?
4. What happens when you TOUCH it?

Let’s give it a try!

EXAMPLE: 75 yo male patient with primary hospice diagnosis of COPD. He resides at home and spends most of his time in bed. His significant other is the primary caregiver. Has O2 at 5L per nasal cannula. Recent hospitalization for pneumonia.

While this is not a complete patient picture, what might you expect to see, hear, and smell?

Try to imagine the last patient you cared for with a diagnosis of COPD that was declining.

RECOMMENDED ARTICLE: Hospice Documentation, What You Need to Know

Document what you see.

When you interact with the patient, what did you hear?

• Gasping sound when walking to the patient’s room
• Audible wheezing

Use your nose to document what you smell.

• Foul-smelling breath

Now do you get it?

Let your documentation reflect your strong assessment skills!

Step #3: Use Comparison Charting in Hospice Narrative Notes

Decline, Decline, Decline!!!!

We’re in the business of treating the whole patient, not just the symptoms related to their terminal illness.

This started making more sense to me when I started leading IDG meetings in the home hospice setting. (Read more of my story at the end of the post!)

Comparison Data Examples

• Hospice Scales & Measures
• Functional Status
• Wounds
• Pain
• Medication & Treatment Changes
• Level of Care Changes
• Plan of Care Changes

The Hospice Nurse Hero RECERTIFICATION Checklist is my go-to when I admit a patient! I can enter information and if the patient stays on service through the recertification period, then I have their clinical data in one place without digging through the chart!

This is a HUGE time saver!

• Save

Remember, documenting decline means including all the nitty gritty details!

Expert Tip: Use a variety of ranges to compare information i.e. benefit periods, months, weeks, and days. You can reach back to the admission and compare data.

Step #4 Putting It ALL Together

Now, if you’ve done a thorough job in the first three steps, then this is the easy part.

Let’s try it together for a new hospice admission.

A good rule of thumb for admission narratives is to start your note with the patient’s age, sex, admission date, and admission diagnosis.

Admission Narrative Note Example: Patient is a 39-year-old female admitted to hospice on January 12, 2024, with a diagnosis of breast cancer with metastasis to bones and brain.

Then start filling in the gaps with the information you have gathered.

Why hospice? Why Now? (STEP 1)

Patient was diagnosed with right breast cancer in October 2022. She had a right total mastectomy with sentinel node removal. Patient completed chemotherapy and radiation therapy in February 2023. When she returned for six-month scans, she had lesions on her pelvic bones. PET scan revealed metastasis to bones and brain. Patient underwent additional palliative chemotherapy, but cancer did not respond to treatment and now she is seeking comfort care. PPS-40%. Patient lives with her spouse who helps with chores and the kids. Patient is no longer working. (enter any additional data)

Use Your Senses (STEP 2)

Comparison Chart (STEP 3)

Patient is cachectic and expressed that she has a poor appetite due to anxiety. Patient’s face is sunken, and her voice is weak. Writer able to feel patient’s bones through shirt when listening for breath sounds. (enter any additional data)

Prior to admission, the patient reports she was able to move around still and take her kids to school. Currently, she is weak and has not been able to attend events with the kids. Her current weight is 125lbs which is down from 165lbs 6 months ago. States pain has increased, and she has recently had her oxycontin increased from 10mg bid to 20mg bid. Takes oxycodone 5mg po 2-3 times/day for breakthrough pain.

Final Nurse Narrative (STEP 4)

Patient was diagnosed with right breast cancer in October 2022. She had a right total mastectomy with sentinel node removal. The patient completed chemotherapy and radiation therapy in February 2023. When she returned for six-month scans, she had lesions on her pelvic bones. PET scan revealed metastasis to bones and brain. Patient underwent additional palliative chemotherapy, but cancer did not respond to treatment and now she is seeking comfort care. PPS-40%.

The patient lives with her spouse who helps with chores and the kids. Patient no longer working. Patient cachectic and expressed that she has a poor appetite due to anxiety. Patient’s face is sunken, and her voice is weak. Writer able to feel patient’s bones through shirt when listening for breath sounds. Prior to admission, the patient reports she was able to move around still and take her kids to school.

Currently she is weak and has not been able to attend events with the kids. Her current weight is 125lbs which is down from 165lbs 6 months ago. States pain has increased, and she has recently had her oxycontin increased from 10mg bid to 20mg bid. She understands her prognosis and does not wish to return to hospital and is seeking comfort measures only. (Add any additional pertinent information)

BONUS: Pro Tips for Stellar Documentation:

Be the Sherlock Holmes of Assessment: Seek out those symptoms, collaborate with your team, and let your documentation be the evidence of your detective work.

Show, Don’t Tell: Make your patient’s response to interventions pop off the page. Let the clinical record be a visual testament to the positive impact you’re making.

Team Spirit in Writing: Shout out to collaboration! Make sure your documentation matches that of the team. Teamwork makes the dream work, right?

FINAL THOUGHTS

So, there you have it. A simple 4-step process for building strong hospice nurse narrative notes!

Your narratives are the glue that holds everything together. They help your team understand what’s happening, they guide future care decisions, and they ensure your patients get the personalized attention they deserve.

Most importantly, they “paint the picture” to support hospice eligibility and ongoing hospice care.

So, next time you’re jotting down your notes and assessments, remember – you’re not just documenting, you’re storytelling. Your hospice narratives are a powerful tool, a way to make a lasting impact on the lives you touch.

MY POINT OF VIEW: My first hospice job was at a hospital with two inpatient hospice beds. I didn’t always worry about eligibility requirements because I knew my patients were imminently dying. Many were transfers from other units that sent them to us because they were not going to make it.

As a result, I didn’t worry much about slow decline or trying to prove the patient needed hospice.

It wasn’t until I started working in the field that I realized that patients don’t always decline rapidly or on a normal trajectory.

Home hospice was my introduction to “negative charting.”

Some hospice nurses view the term negative charting as a bad thing. Well, I don’t!

Negative charting shows that you’ve got your eyes on every symptom, even the unrelated ones.

As a hospice nurse, you should embrace the patient’s whole story, because it’s not just about medications; it’s about caring for the person behind the illness.

-Sincerely, Rochelle