Hospice Election and Coordination Form
Hospice Election and Coordination Form template for documenting election details, plan of care, visit schedule, and minimum-necessary information sharing between a facility and hospice agency.
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Built for: Hospice Care · Skilled Nursing Facilities · Assisted Living · Long Term Care
Overview
The Hospice Election and Coordination Form template is built for the handoff between a facility and a hospice agency after hospice election. It organizes the resident and facility contact details, election confirmation, attending physician information, plan of care, symptom focus, medication coordination, DME or supply needs, and the initial visit schedule in one place.
Use this template when a resident has elected hospice and the facility needs a clear record of who is responsible for what, when services begin, and what information can be shared. It is especially useful when multiple people are involved in the transition, such as nursing staff, social services, the hospice intake team, and the attending physician. The consent and minimum-necessary acknowledgment fields help keep the workflow aligned with privacy expectations while still supporting care coordination.
Do not use this form as a substitute for the hospice plan of care itself, daily clinical documentation, or a full medical record transfer. It is also not the right tool for non-hospice referrals, broad intake questionnaires, or forms that require extensive symptom history. Keep the scope narrow: document only the fields needed to confirm election, coordinate the first visit, and reduce missed handoffs. When used this way, the form gives both sides a clean, auditable snapshot of the resident’s hospice start process.
Standards & compliance context
- The template supports GDPR Article 5 data minimization by limiting collection to coordination fields that are needed for hospice handoff.
- The consent and disclosure section helps document authorization for sharing PHI and other resident information with the hospice agency.
- The form can be configured to follow the minimum-necessary principle by hiding nonessential fields unless they are relevant to the care transition.
- If the form is exposed to residents or family members, labels and controls should meet WCAG 2.1 AA accessibility expectations.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Resident and Facility Information
This section identifies the resident and the facility contact points so the hospice agency can route coordination questions without exposing unnecessary details.
-
Resident Identifier
Use the facility MRN, chart number, or other internal identifier. Avoid collecting SSN or full DOB unless required by policy.
- Facility Name
- Unit / Room
- Facility Contact Name
- Facility Contact Phone
- Facility Contact Email
Hospice Election Details
This section confirms that hospice election occurred and records the attending physician and election scope needed for the handoff.
- Hospice Agency Name
-
Hospice Election Date
Date the resident elected hospice services.
-
Election Confirmed by Agency
Confirm that the hospice agency has acknowledged the election and is coordinating services.
-
Attending Physician Name
Enter the attending physician if known and relevant to coordination.
- Attending Physician Phone
- Services to Coordinate
Plan of Care and Clinical Coordination
This section captures the care plan, symptom focus, and any medication or supply needs that affect the first days of hospice service.
-
Plan of Care Received
Check when the hospice plan of care has been received or shared with the facility.
- Primary Symptom Focus
-
Special Instructions
Include only instructions needed for safe coordination and continuity of care.
- Medication Coordination Needed
- Medication Notes
- DME / Supply Needs
Visit Schedule and Service Start
This section sets the start date and visit cadence so both teams know when the first nurse visit happens and how often follow-up visits are expected.
- Planned Service Start Date
- Initial Nurse Visit Date and Time
- Planned Visit Frequency
-
Visit Schedule Notes
Include preferred visit windows, after-hours instructions, or coordination constraints.
Consent, Disclosure, and Submission
This section documents permission to share information, the minimum-necessary acknowledgment, and the submission audit trail.
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Minimum Necessary Acknowledgment
I confirm this form includes only the minimum necessary information needed for hospice election and care coordination.
-
Consent to Share Information
I confirm that the resident or authorized representative has consented to share relevant information with the hospice agency as needed for coordination.
- Submitted By
- Submission Date
How to use this template
- Enter the resident identifier, facility name, unit or room, and the best facility contact so the hospice agency can route questions to the right person.
- Record the hospice agency name, election date, election confirmation, attending physician details, and election scope using the correct field types and required-vs-optional markers.
- Attach or confirm the plan of care, then note the primary symptom focus, any special instructions, medication coordination needs, and DME or supply needs with only the minimum necessary detail.
- Set the service start date, initial nurse visit, visit frequency, and any scheduling notes so the first visit and ongoing cadence are clear to both teams.
- Have the submitter complete the consent, disclosure, and minimum-necessary acknowledgment fields, then save the submission date to preserve the audit trail.
Best practices
- Use a date picker for election date, service start date, and submission date so the record stays consistent and easy to review.
- Mark only the truly required fields as required, and keep optional fields available for details that may not apply to every resident.
- Use progressive disclosure for medication coordination and DME needs so you only show follow-up fields when those items are needed.
- Keep resident identifiers limited to what the facility and hospice agency need for matching records, and avoid collecting extra PII.
- Capture the initial nurse visit and visit frequency in a structured format instead of free text whenever possible.
- Document special instructions in plain language that the hospice team can act on immediately, such as access notes or after-hours contact expectations.
- Confirm consent to share information before submission so the form does not become a downstream privacy problem.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this template used for?
This template records the key handoff details between a facility and a hospice agency after hospice election. It captures resident identification, election confirmation, attending physician information, plan of care, visit frequency, and consent to share information. The goal is to keep coordination clear while limiting PHI to what is necessary for care.
Who should complete the form?
It is typically completed by a facility nurse, case manager, social worker, or admissions coordinator, then reviewed with the hospice agency. The submitted-by field helps create an audit trail for accountability. In many workflows, hospice and facility staff each confirm their own sections before service starts.
How often is this form used?
Use it at hospice election and again whenever the care plan, visit schedule, or coordination needs change. It is not meant to replace daily charting or ongoing clinical notes. Many teams also reuse it during transitions, such as a new attending physician, updated DME needs, or a change in symptom focus.
Does this form collect more PHI than necessary?
It should not. The template is structured around minimum-necessary data collection, so you can document coordination details without adding unrelated identifiers or sensitive history. If your workflow does not require a field, keep it optional or use progressive disclosure to avoid over-collecting PII.
What should be included in the visit schedule section?
Include the service start date, the initial nurse visit, the expected visit frequency, and any scheduling notes that affect access or timing. If the schedule depends on symptoms, family availability, or facility routines, capture that in the notes field. This helps reduce missed visits and confusion at handoff.
How does this template support consent and disclosure requirements?
The consent section documents that information sharing is authorized and that the user acknowledges minimum-necessary disclosure. That makes the form easier to use in regulated workflows and helps clarify what can be shared with the hospice agency. It also creates a cleaner record of who submitted the form and when.
Can this be customized for different facilities or hospice agencies?
Yes. You can rename fields, add conditional logic for medication coordination or DME needs, and adjust the visit schedule section to match local workflow. Keep required fields limited to what is truly needed, and use validation so dates, phone numbers, and confirmation fields are entered consistently.
What are the most common mistakes when using this form?
Common issues include leaving election confirmation blank, entering free-text dates instead of a date picker, and collecting detailed clinical information that is not needed for coordination. Another frequent problem is skipping the consent or minimum-necessary acknowledgment, which weakens the record. Clear field labels and required-vs-optional markers help prevent those errors.
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