LCD L34538 / L33393Free — notepush.com

IDG / IDT Meeting Documentation — Hospice Visit Note Template

The IDG is the clinical and compliance backbone of every benefit period. CMS requires a meeting at least every 15 days. This template captures per-discipline updates, care plan changes, and the eligibility narrative that protects you at recertification.

LCD L34538 / L33393 Quick Check

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Meeting frequency ≤ 15 days from last IDG

Document date of last meeting

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All required disciplines represented or documented absent

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Plan of care reviewed and updated

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Terminal prognosis reaffirmed with clinical rationale

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Patient/family goals of care confirmed or updated

Check all boxes before filing.

Meeting Information

Meeting date

Meeting time

Benefit period number

Days since last IDG(must be ≤ 15)

Next IDG date

Patient name / MRN

Primary diagnosis

LCD (circle)

☐ L34538☐ L33393

Admit date / benefit period start

Day of current stay

Attendees (mark present ✓ or absent A)

☐[ ] Physician / Medical Director — name: ___

☐[ ] Registered Nurse — name: ___

☐[ ] Social Worker — name: ___

☐[ ] Chaplain / Spiritual Care — name: ___

☐[ ] Hospice Aide / CNA — name: ___

☐[ ] Dietitian — name: ___

☐[ ] Volunteer Coordinator — name: ___

☐[ ] Bereavement Coordinator — name: ___

☐[ ] Other: ___

☐[ ] Patient / family representative present — name: ___

Nursing Update

Current PPS

PPS at last IDG(direction of change: ___)

Weight today(lbs | Last IDG: ___ lbs | Trend: ___)

Vital signs summary

Key clinical changes this period

Skin integrity / wounds

Pain management status

Symptom burden summary

Medication changes this period

Hospitalizations / ER visits since last IDG(Y / N — dates, reason)

FAST stage (if dementia)(substage: ___ — verbal output: ___)

SpO₂ / O₂ dependency (if pulmonary)

Social Worker Update

Patient / family coping status

Caregiver burden assessment

Psychosocial concerns / interventions

Community resources arranged or pending

Financial / insurance issues

Safety concerns identified(Y / N — describe)

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Free template — 10 sections

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

✓Meeting Information

✓Attendees (mark present ✓ or absent A)

☐Nursing Update

☐Social Worker Update

☐Chaplain / Spiritual Care Update

☐Aide Services Update

☐Goals of Care Review

☐Eligibility Review & Prognosis Reaffirmation

☐Plan of Care Changes

☐Signatures

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