Keep every patient, family visit, care plan and on-call note on one record.

Hospice care is delivered by a team, not by one clinician. Nurses, aides, a social worker, a chaplain, volunteers and a medical director each see the patient at different times, often in different places, and each needs to know what the others did.

Most providers hold this across a clinical record, a visit calendar, an equipment list and a billing file. Handover between disciplines then depends on phone calls and on notes passed on after each visit. Gaps appear there.

An intake coordinator receives a referral from a hospital, a physician or a family and records the diagnosis, the address and who is the main caregiver. A nurse completes the admission visit, and the medical director signs the certification and the first orders as your regulator requires. The care plan is then written with the patient and family.

Each day, nurse case managers plan visits by area and by how unwell each patient is. Aides arrive for personal care, and the social worker meets families about practical and emotional needs. The chaplain or a volunteer visits where asked. Every visit leaves a note. After hours, an on-call nurse answers the phone.

The interdisciplinary team meets on a set rhythm to review each patient. Equipment such as a hospital bed or an oxygen concentrator goes out to a home and later comes back for inspection, and comfort medicines are kept ready. After a death, the bereavement coordinator follows the family for the period the provider offers. Billing is raised for the payer.