Hospice General Inpatient (GIP) Eligibility Documentation

Documents the clinical justification for hospice general inpatient level of care when acute symptom management cannot be safely or effectively controlled in another setting.

Patient and Encounter Details

• Patient Identifier
  Use the patient MRN or internal identifier. Do not enter SSN.
• Encounter Date
• Documenting Clinician
• Care Setting Prior to GIP
• If Other, specify care setting
• GIP Start Date

Acute Symptom Crisis

• Primary Symptom Driving GIP
• If Other, specify primary symptom
• Current Symptom Severity
• Symptom Onset or Change
• Clinical Description of the Acute Crisis
  Describe the observable findings, escalation pattern, and why the symptom crisis is urgent.
• Is there an immediate safety risk related to the symptom crisis?

Interventions Attempted

• Interventions Attempted
• If Other, specify intervention
• Response to Interventions
  Document whether symptoms improved, partially improved, or remained uncontrolled.
• Why Lower Level of Care Is Not Sufficient
  Explain why the symptom burden cannot be safely managed in home, assisted living, or skilled nursing at this time.

Clinical Justification and Plan

• Clinical Justification for GIP
  State the specific clinical facts supporting general inpatient level of care.
• Expected Goal of GIP Stay
• If Other, specify goal
• Planned Reassessment Frequency
• Plan for Ongoing Management

Consent, Attestation, and Review

• I confirm that only minimum necessary patient information was collected for this documentation.
• Anonymous submission requested
  Use only if your workflow supports anonymous clinical review or de-identified quality reporting.
• Clinician Attestation
  By signing, you attest that this documentation accurately reflects the clinical basis for GIP eligibility and the current plan of care.
• Additional Notes