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Hospice Care Checklist Form Template

Streamline Hospice Care with Our Essential Checklist

Managing hospice care can be overwhelming when you want to ensure every detail is covered. This template helps caregivers and health professionals effectively track and communicate essential elements for patient comfort and care. Enjoy streamlined documentation, improved patient and family satisfaction, and a clear roadmap for compliance with regulations-perfect for hospice recertification, patient intake, or quality assurance. Use the live template to get started.

Use this Template (FREE) Live Preview
Patient full name
Patient date of birth
Primary contact person full name
Primary contact phone number
Relationship to patient
Please Specify:
Has a clinician diagnosed the patient with a life-limiting illness?
Yes
No
Unsure
Has a clinician estimated a prognosis of 6 months or less?
Yes
No
Unsure
Is the patient experiencing an overall decline in health or function?
Yes
No
Unsure
Is the current goal of care to focus on comfort and quality of life?
Yes
No
Unsure
Which symptoms are currently present?
Please Specify:
How satisfied is the patient with current pain control?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Which activities require assistance (select all that apply)?
Are any mobility aids currently used?
No aids needed
Cane
Walker
Wheelchair
Bedbound
Not sure
Which medical equipment is needed in the next 2 weeks?
Please Specify:
Are there any home safety concerns to address?
Primary physician or clinic (name and contact if known)
Is there an advance directive or living will?
Yes
No
Unsure
Preferred place of care
Home
Nursing facility
Assisted living
Inpatient hospice center
Hospital
Not sure
Primary caregiver availability
Available full-time
Available part-time
Available intermittently
Not available
Not sure
Do you consent to be contacted by the hospice team about services?
Yes
No
Preferred contact methods
Phone call
Text message
Email
Video call
Name of person completing this form
Date
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Paper art illustration featuring a hospice care checklist with various tasks and considerations for end-of-life care.

When to use this form

Use this template during admission, routine visits, recertification checks, and after a hospital readmission. It helps you confirm goals of care, current symptoms, medications, equipment, caregiver capacity, and safety risks in one pass. Nurses, social workers, chaplains, and schedulers get the same snapshot, which speeds decisions and reduces documentation gaps. It is also useful before IDG meetings and survey prep so you capture the must-haves regulators expect. When you update orders, align notes with the Home health certification and plan of care form to keep directives consistent. For round-the-clock coverage, pair it with the Home care timesheet form to schedule visits and spot gaps.

Must Ask Hospice Care Checklist Questions

  1. What are the patient's goals of care for this week?

    Clear goals guide medication choices, visit frequency, and how you coach family. They also keep the team aligned during IDG and reduce last-minute changes.

  2. Which symptoms are present now and how severe (pain, breathlessness, nausea, anxiety)?

    A current symptom snapshot drives triage and timely interventions. Rating severity helps you escalate to the right clinician without delay.

  3. Which medications and comfort kit supplies are on hand, and what refills or new orders are needed?

    This prevents lapses in pain control and avoids emergency calls. It also prompts proactive pharmacy coordination and eliminates guesswork during after-hours visits.

  4. Who is the primary caregiver and backup, and what training or help do they need?

    Knowing the support network helps you plan safe handoffs and reduce burnout. Use the Home health aide skills checklist form to confirm competency for tasks like transfers, skin care, and feeding.

  5. Is a facility transfer or respite stay being considered in the next 7 days?

    Planning early prevents gaps in care, transport issues, and family stress. If appropriate, guide the family to the Nursing home application form to streamline placement.

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