The Case. Raymond is an 87 yo WW2 vet with end-stage COPD who also has htn, T2DM, and a history of MI 15 years ago Ray’s dyspnea has worsened over the past 1-2 years and he now spends much of his day confined to his recliner
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Amanda Sommerfeldt, MD
Medical Director, Hospice of Mercy
November 5, 2012
Age at enrollment
City of residence
Presence of dependents in the home and relationship of dependent(s) to patient
Mason City, Charles City, Hampton, Forest City, MNIU
Date of admission
Date of discharge if discharged alive
Date of death
Location of death
Death while receiving hospice services (Y/N)Data Collected
Advance Directive or Living Will
Is AD on file in the chart?
Date completed if known
Is DPOA-HC on file in the chart?
Date completed if known
Code Status Information
Code status at admit
Decision maker(s) at admit
Code status change
Date of change if applicable
Person(s) changing code status
Code status outcome
Was patient coded?Data Collected (cont)
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