LCD L34538 / L33393Free — notepush.com

Hospice Aide Care Plan — Hospice Visit Note Template

The aide care plan must be individualized, authorized by the RN, and updated at each care plan review. A generic aide plan is a compliance gap — it signals to auditors that care isn't being tailored to the patient's functional status.

LCD L34538 / L33393 Quick Check

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RN assessed and authorized the plan

Aide plan must be supervised by an RN

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Tasks are specific to this patient's functional status

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Safety risks identified and mitigating instructions included

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Reporting criteria documented — what the aide should call the nurse about

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Plan updated within the current benefit period

Check all boxes before filing.

Patient & Plan Information

Patient name / MRN

Primary diagnosis

PPS

Aide visit frequency(___x/week, ___ hours/visit)

Preferred visit days/times

Plan effective date

Plan review date

Authorizing RN name

Primary caregiver present during visits(name / relationship)

Safety & Environment

Fall risk

☐ High☐ Moderate☐ Low

Fall risk precautionsside rails, non-slip footwear, assist level

Transfer method / equipment requiredHoyer lift / gait belt / 2-person / board — describe

Skin integrity concerns to monitor

Dysphagia / aspiration precautionspositioning, texture, pace

Home safety concernsclutter, oxygen, sharps, medications

Pets / other factors

Emergency contacts posted / accessible(Y / N — location: ___)

Personal Hygiene & Grooming

Bathing

☐ Full bed bath☐ Partial bed bath☐ Tub bath (with assist)☐ Shower (with assist)☐ Patient preference: ___

Bathing assistance level

☐ Total care☐ Hands-on assist☐ Standby assist / cueing

Bathing frequency(___x/week)

Skin care during bathingproducts to use, areas to avoid, pressure points

☐[ ] Shampoo — frequency: ___ method: ___

☐[ ] Comb / brush

☐[ ] Shave — type: ___ frequency: ___

☐[ ] Nail care (avoid if diabetic / on anticoagulants without RN authorization)

Oral caremethod (toothbrush / swabs), frequency, patient tolerance

Denture care(Y / N — remove at night: Y / N)

Dressing

Assistance level

☐ Total care☐ Assist with lower body☐ Assist with upper body☐ Cueing only

Adaptive clothing or equipment(velcro, front-opening, slip-on shoes)

Special instructionsaffected extremities, IV sites, wounds to protect

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Free template — 10 sections

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What's in the full template (10 sections):

✓Patient & Plan Information

✓Safety & Environment

☐Personal Hygiene & Grooming

☐Dressing

☐Mobility & Positioning

☐Continence & Toileting

☐Nutrition Assistance

☐Reporting Criteria (aide calls RN when)

☐Individualized Goals

☐Authorization

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