Hospice Criteria Checklist

Hospice Criteria Checklist

Identify the condition that is the main contributor to the person's terminal prognosis. Non-specific diagnoses such as Debility or Adult Failure to Thrive (AFTT) may no longer be listed as a principal terminal diagnosis. Debility and AFTT can & should be listed as secondary (related) conditions to support prognosis if indicated.

Patient Name(Required)

HEART DISEASE: The patient has 1 & 2 or 3
Supporting Documentation for HEART DISEASE includes:

LIVER DISEASE: The patient has both 1 & 2
Supporting documentation for LIVER DISEASE includes:

PULMONARY DISEASE: Severe chronic lung disease as documented by 1-3
Supporting documentation for PULMONARY DISEASE includes:

RENAL FAILURE: The patient has 1, 2 & 3
Supporting documentation for CHRONIC RENAL FAILURE:
Supporting documentation for ACUTE RENAL FAILURE:

CANCER: Patient meets ALL of the below:
Supporting documentation for CANCER includes:

STROKE or COMA: Patient has both 1 & 2
Current history of pulmonary aspiration without effective response to speech therapy interventions to improve dysphagia and decrease aspiration events.
Supporting documentation for STROKE or COMA:

NEUROLOGIC DISEASE: Patient must meet at least one of the following criteria (1 or 2A or 2B):
(Criteria are very similar for chronic degenerative conditions such as ALS, Parkinson's, Muscular Dystrophy, Myasthenia, Gravis or Multiple Sclerosis)