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Includes emergency preparedness/acuity level fields, patient demographics, referral and start-of-care dates, insurance identifiers, and supportive assistance details such as marital status and primary caregiver. Provides pain screening using NQF/HIS measures, comprehensive pain location and characteristics, relief and worsening factors, assessment of non-verbal indicators, pain goals, intractable pain criteria, and opioid initiation/continuation timing. Continues with cardiopulmonary monitoring items.",{"@graph":63,"@context":112},[64,80,95],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/initial-and-comprehensive-initial-assessment-hospice-assessment-form-3967p-17/572294/",4,{"url":78,"name":59,"@type":81,"author":82,"headline":59,"publisher":85,"fileFormat":88,"inLanguage":57,"description":61,"dateModified":89,"datePublished":89,"encodingFormat":88,"isAccessibleForFree":90,"interactionStatistic":91},"DigitalDocument",{"name":83,"@type":84},"cksankcs","Person",{"url":68,"name":86,"@type":87},"DocShare","Organization","application/pdf","2026-10-13",true,{"@type":92,"interactionType":93,"userInteractionCount":4},"InteractionCounter",{"@type":94},"ViewAction",{"@type":96,"mainEntity":97},"FAQPage",[98,104,108],{"name":99,"@type":100,"acceptedAnswer":101},"Who is this hospice initial and comprehensive assessment form intended for?","Question",{"text":102,"@type":103},"It applies to patients age 18 and older. The HIS/NQF data collection questions are completed according to the agency’s policy.","Answer",{"name":105,"@type":100,"acceptedAnswer":106},"What pain items must be completed in the form?",{"text":107,"@type":103},"The form includes pain screening (e.g., discomfort because of pain) and a comprehensive pain assessment covering location, severity, character, duration, frequency, and what relieves or worsens pain.",{"name":109,"@type":100,"acceptedAnswer":110},"How is opioid use documented?",{"text":111,"@type":103},"The form records whether scheduled and PRN opioids were initiated or continued and captures the date each was started/continued, with dates defined by hospice receipt of a new order or treatment initiation instructions.","https://schema.org",{"og:url":78,"og:type":114,"og:title":59,"og:site_name":86,"og:description":61},"article",{"robots":116,"canonical":78},"index,follow",{"doc_id":118,"site_id":56},572294,1791926604,{"code":4,"msg":5,"data":121},{"doc_id":118,"user_id":122,"nickname":83,"user_avatar":123,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":124,"file_id":125,"file_url":126,"file_type":127,"file_size":128,"view_count":4,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":20,"language":129,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":130,"faqs":131,"seo_title":132,"seo_description":61,"update_tm":119,"read_time":47},3985747882755,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","INITIAL AND COMPREHENSIVE  \nINITIAL ASSESSMENT HOSPICE ASSESSMENT  \nThe data collected for the Hospice Item Set (HIS) / National Quality Forum (NQF) apply to all patients 18 years of age and older. Complete the NQF / HIS data collection questions according to your agency’s policy. Do not separate Initial and Comprehensive Assessment form.  \nEmergency Preparedness/Acuity Level:   \nPatient Name:  ❑ Male ❑ Female ID \\#:   \nLast First MI  \nReferral Date:  Start of Care Date:  Date of Birth:   Medicare \\#:   Medicaid \\#:    \nName on Card:  Effective Date:  Other Insurance:    \nSUPPORTIVE ASSISTANCE  \nMarital Status: ❑ Single ❑ Married ❑ Divorced ❑ Separated ❑ Widow/Widower ❑ Significant other ❑ Other:   Primary Caregiver:  Relationship:  Willing to provide all of patient care: ❑ Yes ❑ No If no, explain:   Other assistance provided by:   \nCondition at time of admission: ❑ Symptoms controlled ❑ Fair – frequent interventions necessary to control symptoms  \n❑ Poor – rapidly declining ❑ Imminently dying ❑ Terminal restlessness  \nPain Screening: (NQF 1634 / HIS J0900)  \nAre you uncomfortable because of pain? ❑ Yes ❑ No  \n❑ Excluded due to: ❑ Language barrier ❑ \u003C18 years old  \n❑ Unable to report due to: ❑ Pt. condition ❑ Other:   \nComprehensive Pain Assessment:  \n1. Pain Location: (NQF 1637 / HIS J0910)  \nSite(s) specify:   \n_______________________________________________________  \n2. Severity: (using scales below)  \nWong-Baker FACES Pain Rating Scale  \n0 1 2 3 4 5 6 7 8 9 10  \nNo Moderate Worst  \nPain Pain Possible Pain  \nMedical Professionals Please Note:  \nExplain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn’t hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don’t have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling.  \n**From Wong D.L. , Hockenberry-Eaton M. , Wilson D. , Winkelstein M.L. , Schwartz P.: Wong’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission. Present level of pain:  Worst pain gets   \nBest pain gets  Acceptable level of pain   \n3. Character: ❑ Aching ❑ Nagging ❑ Dull ❑ Heavy ❑ Crushing  \n❑ Sharp ❑ Stabbing ❑ Throbbing ❑ Radiating ❑ Burning  \n❑ Tingling ❑ Cramping ❑ Other:   \n4. Duration: ❑ Constant ❑ Intermittent (length of time)   5. Frequency: ❑ Occasionally ❑ Continuous ❑ Intermittent  \n❑ Other:    \n6. What relieves/worsens pain:  \nWhat makes pain worse? ❑ Movement ❑ Ambulation  \n❑ Other:   What makes pain better? ❑ Heat ❑ Ice ❑ Massage ❑ Repositioning  \n❑ Rest ❑ Relaxation ❑ Medication ❑ Diversion  \n❑ Other:   How often is breakthrough medication needed? ❑ Never  \n❑ Less than daily ❑ 2-3 times/day ❑ Greater than 3 times/day  \n❑ Current pain control medications adequate  \n❑ Other:    \nNon-verbals Demonstrated: ❑ Diaphoresis ❑ Grimacing  \n❑ Moaning ❑ Crying ❑ Guarding ❑ Irritability ❑ Anger  \n❑ Tense ❑ Restlessness ❑ Change in vital signs  \n❑ Other:    \n❑ Self-assessment ❑ Implications:    \n____________________________________________________  \n____________________________________________________  \n7. Effect on function or quality of life:    \n______________________________________________________  \n______________________________________________________  \nIs pain an active problem? ❑ Yes ❑ No (HIS J0905)(Consider all elements of comprehensive even if present level is 0)(NQF 1617/ HIS N0500A) Was a scheduled opioid initiated or continued? ❑ No ❑ Yes  \n(NQF 1617/ HIS N0500B) If yes, what is the date the scheduled opioid was initiated or continued?   /  /  (This is the date that (1) the hospice received a new order to initiate or to continue regularly scheduled opioid(s) OR (2) for comfort kits or pre-printed admission orders, treatment is initiat","cbCaiczL9X4QnE2x","https://ap.wps.com/l/cbCaiczL9X4QnE2x","pdf",442175,"English","# Hospice Assessment Intake\n## Emergency preparedness/acuity level\n## Supportive assistance and admission condition\n## Pain screening and comprehensive pain assessment\n## Pain goals and intractable pain\n## Opioid initiation/continuation documentation\n## Cardiopulmonary assessment","[{\"question\":\"Who is this hospice initial and comprehensive assessment form intended for?\",\"answer\":\"It applies to patients age 18 and older. The HIS/NQF data collection questions are completed according to the agency’s policy.\"},{\"question\":\"What pain items must be completed in the form?\",\"answer\":\"The form includes pain screening (e.g., discomfort because of pain) and a comprehensive pain assessment covering location, severity, character, duration, frequency, and what relieves or worsens pain.\"},{\"question\":\"How is opioid use documented?\",\"answer\":\"The form records whether scheduled and PRN opioids were initiated or continued and captures the date each was started/continued, with dates defined by hospice receipt of a new order or treatment initiation instructions.\"}]","INITIAL AND COMPREHENSIVE - Initial Assessment Hospice Assessment - Form 3967P-17 | PDF"]