National Hospice and Palliative Care Organization

National Hospice and Palliative Care Organization

Patient Outcomes and Measures (POM)

Comfortable Dying Data Submission Worksheet

Directions: Please use this worksheet to compile your information before submitting data online through the NHPCO DART System. Should you have questions regarding any part of the POM data collection and reporting process, please direct them to our dedicated e-mail address: .

SECTION A: CONTACT INFORMATION

Hospice Profile

A1. NHPCO DART ID __________

A2. Hospice Full Name ________________________________

A3. State ______

Contact Person

A4. First Name ________________________

A5. Last Name ________________________

A6. Phone ___________________________

A7. Email ___________________________

SECTION B. REPORTING PERIOD

B1. Quarter and year of data collection: Quarter ___ Year ______

B2. Admissions: Number of patients admitted during this quarter: ______

SECTION C. DATA COLLECTION FOR COMFORTABLE DYING MEASURE

Question on Admission: "Are you uncomfortable because of pain?"

C1. Number of patients who answered "yes": ______

C2. Number of patients who answered "no": ______

C3. Number of patients excluded (not eligible): ______

Question after 48 hours: "Was your pain brought to a comfortable level within 48 hrs of the start of hospice care?"

Note: Only asked of patients who reported being uncomfortable due to pain on admission (C1).

C4. Number of patients who answered "Yes": ______

C5. Number of patients who answered "No": ______

C6. Number of patients unable to self-report at follow-up: ______

Note: The total number of patients in C4, C5, and C6 should equal and must not exceed the total number of patients reporting discomfort due to pain on admission (C1).

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