How to Write Hospice Narratives That Pass Audits

When surveyors or auditors review hospice records, one of the first things they look at is the narrative—the physician’s or nurse practitioner’s summary that explains why the patient continues to meet hospice eligibility. Narratives are not just a regulatory requirement; they are the story that ties together all charted data, showing evidence of terminal decline and supporting the six-month prognosis.

But many hospice agencies struggle with narratives. Too often, they are vague, repetitive, or overly positive—leading to Medicare denials, compliance risks, and financial penalties.

In this article, we’ll break down how to write hospice narratives that pass audits. You’ll learn what auditors look for, common mistakes to avoid, and how to structure narratives so they are clear, compliant, and effective.

Why Narratives Matter in Hospice

Compliance with Medicare CoPs

The Medicare Conditions of Participation (CoPs) require that a physician or nurse practitioner document a narrative explaining the clinical findings that support ongoing hospice eligibility. Without this, recertification is invalid.

Survey and Audit Readiness

MACs (Medicare Administrative Contractors) frequently deny claims because narratives fail to show decline. A strong narrative protects your agency during audits.

Clinical Communication

Narratives summarize the patient’s condition in a way that all members of the interdisciplinary group (IDG) can understand.

Advocacy for the Patient

A well-written narrative validates the need for continued hospice, ensuring patients don’t lose access to needed care.

What Auditors Look For

When reviewing narratives, auditors want to see:

• Evidence of decline over time (not stability or improvement).

• Specificity, with measurable data and examples.

• Consistency across disciplines (nursing, social work, therapy, physician notes).

• Comparative statements (“compared to last certification…”).

• Alignment with LCD criteria (disease-specific guidelines from CMS).

If the narrative is vague or contradictory, auditors may conclude the patient is not eligible—leading to denials.

Common Mistakes in Hospice Narratives

1. Copy-and-Paste Narratives

   • Using the same wording across certifications suggests no change.

   • Auditors may assume the patient is stable.

2. Overly Positive Language

   • Phrases like “patient doing well” or “no complaints” undermine eligibility.

   • Narratives must focus on decline, not stability.

3. Lack of Specific Data

   • Saying “weight loss noted” is weak. Instead: “10% unintentional weight loss in six months.”

4. Ignoring Non-Physical Decline

   • Cognitive, psychosocial, and functional decline matter as much as physical changes.

5. Too Short or Too Generic

   • Narratives that are one or two lines don’t meet Medicare’s standard of individualized explanation.

How to Write Strong Hospice Narratives

1. Start with Disease-Specific Criteria

• Anchor the narrative in LCD guidelines (e.g., dementia, COPD, CHF).

• Example: “Patient with end-stage COPD meets LCD criteria due to dyspnea at rest, oxygen dependence, and progressive decline in functional status.”

2. Include Objective Measurements

• Weight: “Patient has lost 12 lbs in the last 3 months, representing 9% of body weight.”

• ADLs: “Now dependent in 5 out of 6 ADLs, requiring total assistance with bathing, dressing, and feeding.”

• Functional Scales: FAST 7C, PPS 30%, NYHA Class IV, etc.

3. Highlight Comparative Decline

Auditors want to see change over time:

• “At last certification, patient was able to ambulate with a walker. Now bedbound and requires two-person assist for transfers.”

• “Previously consumed 50% of meals; now taking only sips of liquids.”

4. Describe Symptoms and Their Impact

• Dyspnea, pain, agitation, confusion, frequent infections.

• Example: “Despite scheduled morphine, patient continues to experience pain rated 7/10 when repositioned.”

5. Incorporate Caregiver Reports

Family and caregiver observations strengthen the narrative:

• “Daughter reports patient has not spoken more than single words in the past two weeks.”

6. Address Non-Disease-Specific Decline

Include evidence of general deterioration:

• Unintentional weight loss.

• Frequent hospitalizations.

• Increased sleep (>18 hours/day).

• Declining oral intake.

7. Use Clear, Concise, and Professional Language

Avoid vague or emotional language. Stick to clinical, measurable, and comparative statements.

Narrative Writing Formula

Here’s a simple structure you can teach your team:

1. Intro Statement: Diagnosis + disease-specific eligibility.

   • “Patient is an 86-year-old female with end-stage Alzheimer’s disease at FAST 7D.”

2. Objective Decline: Clinical measurements.

   • “She has lost 15 lbs in six months (11% of body weight), now weighs 118 lbs.”

3. Functional Decline: ADLs and activity.

   • “Previously ambulatory with assistance, she is now bedbound and requires total care for all ADLs.”

4. Symptom Burden: Pain, dyspnea, infections.

   • “Patient has had two episodes of aspiration pneumonia in the last 60 days and requires continuous oxygen.”

5. Caregiver Input:

   • “Family reports patient is now nonverbal and consumes less than 25% of meals.”

6. Closing Statement: Six-month prognosis summary.

   • “These findings support continued hospice eligibility with life expectancy of six months or less if disease runs its natural course.”

Sample Narratives
Dementia Example

Weak Narrative:
“Patient has dementia, requires help with ADLs, continues on hospice.”

Strong Narrative:
“Patient is an 88-year-old female with end-stage Alzheimer’s disease, FAST 7F. She is nonverbal and unable to recognize family. Previously able to feed self with cueing, she now requires staff to feed all meals. Weight has declined from 132 lbs to 118 lbs in 4 months (11% loss). Patient is bedbound, incontinent of bowel and bladder, and sleeps 18–20 hours daily. Family reports increased withdrawal and minimal interaction. These findings demonstrate continued decline and support a six-month prognosis.”

COPD Example

Weak Narrative:
“Patient has COPD and shortness of breath.”

Strong Narrative:
“Patient is a 76-year-old male with end-stage COPD. He is dyspneic at rest with O2 sat 85% on 4L NC. Previously able to walk short distances with a walker, he is now confined to a wheelchair and requires assistance with all ADLs. Appetite has decreased, and patient has lost 14 lbs in three months. Despite optimal medical therapy, he continues to experience exacerbations, with two ER visits in the last 60 days. These findings support eligibility with life expectancy of six months or less.”

Tips to Ensure Narratives Pass Audits

• Audit Internally: Review narratives before submission.

• Avoid Templates Alone: Templates can guide, but every narrative must be individualized.

• Train Staff Regularly: Hold workshops on LCDs and documentation standards.

• Consistency is Key: Nursing, physician, and IDG notes should all support the narrative.

• Think Like an Auditor: Ask: Does this narrative tell the story of decline?

Conclusion

A hospice narrative is more than paperwork—it is the clinical story that demonstrates decline, supports eligibility, and protects your agency during audits. Weak or generic narratives risk denials, while strong, detailed narratives show clear evidence of decline and ensure compliance.

By following a structured approach—anchoring in disease-specific criteria, documenting objective and functional decline, including caregiver input, and writing with comparative detail—your agency can consistently create hospice narratives that pass audits.