How To Paint the Picture:10 Better Words to Chart

This article will outline tips and strategies to support better hospice documentation when painting the picture of decline.

“Painting the picture” is a phrase often used to describe the process of documenting a hospice patient’s condition. Additionally, it’s a way of documenting decline that captures the patient’s physical, emotional, and spiritual needs.

Furthermore, documenting decline is not only for ensuring quality care but also for meeting Medicare documentation requirements for hospice eligibility and recertification.

I’ll be honest. I didn’t always understand how to chart for hospice. When I started as a hospice nurse, I struggled with the concept of “negative” charting.

Also, one of the things that helped me the most was when one of my colleagues educated me that each note should be able to stand alone.

💡PRO- TIP: Each time you chart, your documentation should use words and phrases that support ongoing eligibility.

So, let’s get into it.

Understanding the Art of Painting the Picture

To “paint the picture” in hospice documentation means to describe a patient’s condition and decline with such clarity and detail that anyone reading the notes can visualize the patient’s situation.

For instance, this involves using descriptive words that convey the severity and impact of symptoms.

It also means charting disease-specific signs of decline.

Most importantly, it’s about creating a vivid, comprehensive narrative that confirms the patient’s need for hospice care under Medicare guidelines.

As a rule, I always found that capturing decline when a patient comes into hospice is the easy part. Usually, there has been an event or something traumatic that has led up to the decision to sign up for hospice.

However, when you see your patient 2–3 times per week, it becomes more challenging to spot subtle changes.

Would you agree?

Let’s take a look at some descriptive words that can be used to communicate changes in your patient.

Descriptive Words for Hospice Patients

First, effective hospice documentation uses precise, descriptive language to articulate the patient’s condition.

For example, words such as “labored breathing,” “severe pain,” “unable to swallow,” “significant weight loss,” or “continuous decline in cognitive function” are specific and illustrative. These descriptions offer a clear picture of the patient’s state and the progression of their illness.

Additionally, adding explanations to the words will paint the picture for the members of your IDG.

For instance, compare the two examples below and decide which one tells you more about what is going on with the patient.

**Documentation Dos and Don’ts For Painting the Picture**

To begin, each example below can appear in the chart. However, the second example has more details demonstrating how the patient is declining.

Example #1: Routine Visit (Don’t)

Patient resting in bed upon arrival. Patient alert and responsive. Requires assistance with ADLs. Appetite continues to decline. Family states the patient is sleeping more and has not wanted to get out of bed lately. Denies pain. Discussed s/s of decline and encouraged to call with any concerns. Reviewed hospice philosophy. Patient and family verbalized understanding.

Example #2: Routine Visit (Do)

Upon arrival, the patient was found in bed with eyes closed. Patient alert to person and place. The family expressed that the patient has periods of confusion and is sleeping more during the day. The family states that the patient is in bed 16 hours per day, which has increased from 12 hours per day in the last couple of days. Patient used to get out of bed to the chair but has decreased interest in activities and is sleeping 14–16 hours per day. Requires assist of two to transfer from bed to chair. PPS is now 40%. Family states that they have to awaken the patient to encourage them to eat meals.

The patient was eating 3 meals each day and is now eating 25-50% of meals.

Reviewed medication and supplies. Discussed hospice philosophy and encouraged to call the exchange with any needs or concerns. V/U.

Explanation of Examples

As you can see in example #2, adding explanations to the note helps the reader visualize the scene and helps to paint the picture.

🎯🎯🎯I love it when the nurse’s note contains the PPS.🎯🎯🎯

BONUS: Make comparison charting easier by adding PPS to your nursing notes as that patient’s condition changes! This is a key to painting the picture.

How to Chart Hospice Decline

Charting hospice decline involves systematically documenting changes in the patient’s condition demonstrating a trajectory towards end-of-life. This includes:

Physical Symptoms: Note any new symptoms or the worsening of existing ones, such as increased pain, nausea, or respiratory distress. Use scales like the Karnofsky Performance Scale (KPS) or the Palliative Performance Scale (PPS) to quantify changes.
Functional Abilities: Document declines in the patient’s ability to perform daily activities, highlighting any new dependencies, such as the need for assistance with walking, eating, or personal care.
Cognitive and Emotional Status: Record any noticeable deterioration in cognitive functions or significant emotional distress, including confusion, anxiety, or withdrawal.
Disease-Specific Declines: Each condition presents unique markers of decline. For example, a patient with heart failure might exhibit increased edema, while someone with ALS might show a rapid decline in respiratory function.

Want More Charting Tips? Check out this Article on Recertification Documentation Tips and Strategies

Painting the Picture to Support Decline:

Progressive Decline in Health: Documenting the patient’s decline in health is one way to demonstrate the trajectory they are on. This can include worsening symptoms, decreased functional status, or increased dependence on ADLs.

Failure to Respond to Treatment: You should note the patient’s lack of response to current treatments for pain and symptom management.

For instance, if your patient has been receiving pain medication, but their pain remains uncontrolled. You should document interventions that you tried and how it worked.

Get as detailed as possible. Remember, if a surveyor were to read your note, would they have an idea of what happened and what the plan is?

Additional Supportive Needs: If additional members of the IDG are consulted for the patient, make sure to highlight this in your notes. This is a good way to show collaboration. It also highlights the complex needs of the patient.

📝True Story: During one of our surveys, we avoided a deficiency because the surveyor said they could see the amount of collaboration that took place by our team in the notes, so they felt confident about the care and attention the patient was receiving!

Objective Data: Routine measurements such as weight, mid-upper arm circumference (MUAC), and PPS are simple ways to demonstrate clinical decline. Also consider, how their clothes fit. You might even document changes in diaper sizes.

Subjective Data: This information comes from your patients, families, caregivers, and friends. This includes pain and feelings. When documenting subjective measures, it is important to add descriptors.

Establishing Recertification Eligibility

For recertification, Medicare requires evidence of continued decline despite appropriate palliative care. “Paint the picture” by documenting:

Progression of Disease: Detail the disease’s progression since the last certification, using disease-specific markers.

For example, if you understand what disease progression looks like for the disease, you can document how it differs from the norm.

Let’s give it a try with Liver Disease! What might you see?

Jaundice-yellowing of eyes and skin
Bruising and/or bleeding
Confusion and/or difficulty concentrating
Swelling in the abdomen and legs
Itching (skin)
Dark, concentrated urine

Response to Treatment: Describe the patient’s response to current palliative treatments, emphasizing the lack of improvement or further decline.

For example, the patient who has metastatic disease despite chemotherapy treatment. Lack of pain control with continued need for interventions to manage symptoms.

Decline in Functional Status: Continuously update the patient’s functional status, providing a timeline that showcases ongoing decline.

💡PRO-TIP: Use checklists to track your patient’s decline over time. Additionally, it will save you time when charting for IDG and recertification.

10 Better Words (Phrases) to Chart

The next time you’re charting, try these words and phrases to paint the picture of decline.

Requires– Requires morphine to manage pain and SOB
Decreasing– Decreasing MUAC from 23 to 21 since the last benefit period
Uncontrolled– Pain uncontrolled with current dose of oxycodone
Frequent– Family reports frequent periods of confusion
Increased– Increased fatigue as evidenced by patient unable to tolerate activity. Used to ambulate to bathroom and now uses BSC
As evidenced by– Weight loss as evidenced by ill-fitting clothes, cachexia, protruding bones
Cannot– Cannot ambulate without walker
Needs– Patient needs frequent breaks during care due to difficulty breathing
Recurrent– Recurrent UTI requiring antibiotic on 2/21/2024
Unable-Patient unable to dress themselves

Conclusion

Finally, in hospice care, documentation that vividly “paints the picture” of a patient’s condition and decline is fundamental. It not only supports the provision of empathetic, individualized care but, also, ensures compliance with Medicare requirements for hospice eligibility and recertification. By using descriptive language, meticulously charting the patient’s decline, and establishing eligibility for recertification, hospice professionals can enhance their documentation practices, thereby enriching the quality of care provided to patients at the end of life.

Remember, your documentation is a powerful tool in advocating for your patients’ needs and rights to hospice care. Let’s commit to painting a picture that truly reflects each patient’s journey, ensuring they receive the compassionate care they deserve in their final days.

By incorporating these elements and optimizing for the keyword “paint the picture,” this article aims to serve as an invaluable resource for hospice care professionals seeking to enhance their documentation skills for better patient care and Medicare compliance.