• Only accept terms identified in the list of inclusions. No other terminology will be accepted.
• Determine the earliest day the physician/APN/PA DOCUMENTED comfort measures only. Do not factor in when comfort measures only was actually instituted. E.g., Comfort measures only documentation in a progress note on day 2 which may be linked to day 0 or 1 (e.g., “Discussed comfort care with family on arrival”) – Select “2.”
• Consider comfort measures only documentation in the discharge summary as documentation on the last day of the hospitalization, regardless of when the summary is dictated.
• If any of the inclusions are documented, select “1,” “2,” or “3” accordingly, regardless of other documentation.
• Physician/APN/PA documentation of comfort measures only (hospice, palliative care, etc.) mentioned in the following contexts suffices:
  • Comfort measures only recommendation
  • Order for consultation or evaluation by a hospice/palliative care service
  • Patient or family request for comfort measures only
  • Plan for comfort measures only
  • Referral to hospice/palliative care service
• If DNR-CC is documented, select “4,” unless there is documented clarification that CC stands for “comfort care.”

PHYSICIAN/APN/PA DOCUMENTATION ONLY

• Admitting physician orders
• Consultation notes
• Discharge summary
• Emergency department record
• History and physical
• Physician admitting note
• Physician orders
• Progress notes