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Dementia / Alzheimer's Disease — Hospice Visit Note Template

Use this template at every routine visit to document the specific findings that support hospice eligibility under LCD L34538. FAST staging and the secondary condition are the two most common ADR vulnerabilities in dementia charts.

LCD L34538 Quick Check

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FAST Stage ≥ 7A documented with substage

≥ 7A = ≤ 6 intelligible words/day

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Intelligible word count observed this visit

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Secondary condition present and documented

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PPS ≤ 70%

Most dementia pts: PPS 20–40

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Dependent in ≥ 2 ADLs (documented by name)

Check all boxes before filing.

Visit Information

Date

Visit time / duration

Patient MRN

Benefit period

Vital Signs & Weight Trend

Temp

SpO₂(on RA or __ L O₂)

Weight today(lbs)

Weight last visit (date)(lbs on ___)

Weight change(lbs / %)

6-month weight trend(lbs change over ___ days)

FAST Staging (Required for LCD L34538)

Current FAST Stage— Circle the substage — 'FAST 7' without a letter is not defensible

☐ 7A☐ 7B☐ 7C☐ 7D☐ 7E☐ 7F

Intelligible words observed this visit(Count and list: e.g., said 'no' twice in 60 min, all other vocalizations non-intelligible)

Visit duration for verbal assessment(minutes)

Communication method / response to stimulation

Secondary Condition (Required — document at least one)

☐Aspiration pneumonia / recurrent aspiration — dates: ___

☐Recurrent UTI (≥ 1 in past month) — dates: ___

☐Pressure injury — Stage ___, Location: ___, Size: ___

☐Weight loss ≥ 10% in 6 months — ___ lbs / ___% over ___ days

☐Dysphagia with nutritional compromise — current diet texture: ___

☐Recurrent fever — temp: ___, date(s): ___

☐Septicemia / bacteremia — date: ___

☐Other: ___

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Free template — 13 sections

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What's in the full template (13 sections):

✓Visit Information

✓Vital Signs & Weight Trend

☐FAST Staging (Required for LCD L34538)

☐Secondary Condition (Required — document at least one)

☐ADL Status (document each by name)

☐Palliative Performance Scale

☐Behavioral & Neurological Status

☐Pain & Comfort

☐Nutrition & Hydration

☐Skin Integrity

☐Family / Caregiver

☐Plan & Follow-Up

☐Signature

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