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Accurate and timely patient assessments are crucial to the development of an effective Plan of Care (POC). These assessments address the physical, psychosocial, emotional, and spiritual needs associated with the patient’s terminal illness to promote well-being, comfort, and dignity throughout the dying process.

An initial assessment must be completed by the registered nurse (RN) within 48 hours after the election of hospice care has been completed, unless the physician, patient, or representative requests that the initial assessment be completed sooner. A social worker or other discipline may visit along with the RN to complete the initial assessment. The Hospice may choose their own method for documenting the initial assessment such as in either written or electronic format provided the assessments are complete, readily identifiable, and available in the patient’s clinical record. The assessment should take place at the location where hospice services will be provided/delivered and should not be a visit whereby the Hospice introduces itself to the patient/family and begins to evaluate the patient’s interest in and appropriateness for hospice care. It must assess the patient’s immediate needs (physical, psychosocial, emotional, and spiritual) related to the terminal illness and related conditions and is necessary to gather the essential information needed to begin the POC and provide immediate necessary care and services. 

The RN, in consultation with other members of the IDG/IDT, should consider the information gathered from the initial assessment as they develop the POC. The group will also determine who will visit the patient/family during the first five days of hospice care in accordance with patient/family needs and desire and the Hospice’s own policies and procedures. 

The Hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s needs for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care (§418.54). This comprehensive assessment must accurately reflect the patient’s current health status and include information to establish and monitor a POC.

The Hospice Interdisciplinary Group/Team (IDG/IDT), in consultation with the individual’s attending physician (if any) must complete the comprehensive assessment no later than five calendar days after the election date. If the patient does have an attending physician, one or more members of the IDG/IDT should consult with this physician in completing the comprehensive assessment. The attending physician can often provide a history of the patient’s disease process and family dynamics that can help the Hospice make better care planning decisions that address all areas of need related to the terminal illness and related conditions leading to improved outcomes for the patient. All members of the IDG/IDT must be involved with completing the comprehensive assessment to identify the patient/family’s physical, psychosocial, emotional and spiritual needs and to contribute to the development of the POC to address those needs. 

The comprehensive assessment must be accomplished by the IDG/IDT, in collaboration with the patient’s attending physician (if any) and must consider changes that have taken place since the initial assessment. It must also reflect information on the patient’s progress toward his or her desired outcomes, as well as a reassessment of the patient’s response to the care provided. The assessment update must be completed as frequently as the patient’s condition requires, but no less frequently than every 15 days. The purpose of the updated assessment is to ensure that the IDG/IDT has the most recent accurate information about the patient and the family in order to make accurate care planning decisions. The Hospice is not required to  complete, in full, those documents that they identified as comprising their comprehensive assessment every 15 days, although hospices are free to do so if they so choose. They are required to identify and document if there are no changes in the patient and/or family condition or needs. The updated assessments should also be easily identified in the clinical record.