LCD L34538Free — notepush.com

Cancer (All Types) — Hospice Visit Note Template

Cancer charts are often the strongest in hospice — but ADRs still target them when PPS is borderline or when visit notes don't document continued disease progression. This template captures the functional trajectory auditors are looking for.

LCD L34538 Quick Check

☐

PPS ≤ 70% documented with supporting narrative

☐

Continued disease progression documented

New symptoms, spread, functional decline

☐

Treatment status documented

No treatment / comfort only / declined / exhausted options

☐

Dependent in ≥ 2 ADLs (documented by name)

Check all boxes before filing.

Visit Information

Date

Visit time / duration

Patient MRN

Primary cancer type / site

Benefit period

Vital Signs

Temp

SpO₂

Weight today(lbs)

Weight last visit (date)(lbs on ___)

Weight change / trend(lbs / % over ___ days)

Performance Status

PPS Score— PPS ≤ 70 required — support with narrative

☐ 10☐ 20☐ 30☐ 40☐ 50☐ 60☐ 70

Karnofsky Performance Status— Optional — corroborates PPS

☐ 10☐ 20☐ 30☐ 40☐ 50☐ 60☐ 70

Activity level this visit

Functional change since last visit

Treatment Status

☐No active cancer-directed treatment — comfort measures only

☐Declined further treatment — patient choice documented

☐Treatment options exhausted — per oncologist ___, date: ___

☐Treatment held due to performance status / toxicity

☐Other: ___

Last chemotherapy / radiation / immunotherapy date

Oncologist / treating physician name

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Free template — 10 sections

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

✓Visit Information

✓Vital Signs

☐Performance Status

☐Treatment Status

☐Disease Progression Evidence

☐Pain Assessment

☐Nutrition & Cachexia

☐Other Symptoms

☐ADL Status

☐Goals of Care & Plan

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