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 precautions side rails, non-slip footwear, assist level

Transfer method / equipment required Hoyer lift / gait belt / 2-person / board. Describe

Skin integrity concerns to monitor

Dysphagia / aspiration precautions positioning, texture, pace

Home safety concerns clutter, 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 bathing products 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 care method (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 instructions affected extremities, IV sites, wounds to protect

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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