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General Inpatient (GIP) Documentation Tool

The Carolinas Center for Hospice and End of Life Care Facility-Based Work Group raised questions, faced challenges, discussed, and researched the issue of documentation for the General Inpatient (GIP) level of care. The group produced the attached tool and offers it to hospice agencies as a guide for documentation.

Use of the tool should help those providing GIP in any setting (free-standing facility, long-term care facility, or hospital) to define their own policies and processes. It is not intended to define criteria for GIP. Rather, the tool is intended to guide the Interdisciplinary Team?s critical thinking process in assessment, goal identification, establishment of an effective plan of care, and communication of that plan to all involved in the care.

The sample documentation pieces demonstrate how visits can be documented to reflect the family as the unit of care, IDT communication, and implementation of the plan of care in the context of GIP level of care. Sample documentation is for illustrative purposes only and is not offered as specific phrases or formats to satisfy criteria for GIP.

Use of this tool does not guarantee payment. This tool is not endorsed by any professional agency, governmental agency, or fudicial intermediary.

 

GIP Documentation Tool

 

GIP Quality Review Chart Audit Tool

  • You can download the GIP Quality Review Charrt Audit Tool by clicking here.