The LCD (Local Coverage Determination) documentation included within the nurse chart section of the EMR are used for determining a prognosis of six months or less. Since you are looking for a decline over time, baseline data upon admission should be included. There may be clinical facts not on the following list that support a poor prognosis. Include them in your documentation.
Worsening of Clinical Status, Worsening of Symptoms, and Worsening of Signs are more predictive of poor prognosis with the additional factors providing further support of the prognosis. If the patient doesn't meet the criteria based on these guidelines, a "Non-Disease Specific Baseline", combined with the applicable "Disease Specific" guideline can be used.
CGS has developed a hospice LCD, ID# L34538 titled Hospice Determining Terminal Status, using the National Hospice and Palliative Care Organization's (NHPCO) guidelines.
Refer to the Medical Policies page to access the hospice LCD. https://www.cgsmedicare.com/hhh/coverage/Coverage_Guidelines/LCD.html
*The LCD forms in Hospice Tools are not a requirement. They are there if you want to use them in conjunction to other documentation.