Printable Checklist - IDG Comprehensive Assessment
Interdisciplinary Group (IDG) - All Disciplines

IDG Comprehensive Assessment Checklist

42 CFR 418.54(b) · 42 CFR 418.56 · SOM Appendix M L523, L530–L537, L543, L544

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Patient Name:
Date of Birth:
Election Effective Date:
5-Day Deadline (Day 5):
Assessment completed:
Initial visit type:
5-Calendar-Day Hard Stop: All 7 IDG domains must be completed within 5 calendar days of the hospice election effective date. Single-clinician completion of all domains is a citation risk. Each domain should reflect the responsible IDG discipline. 42 CFR 418.54(b); SOM L523

IDG Composition (42 CFR 418.56(a))

Physician (hospice physician or attending)418.56(a)(1)
Registered Nurse418.56(a)(2)
Social Worker (Masters level)418.56(a)(3)
Pastoral / Spiritual Counselor (chaplain or equivalent)418.56(a)(4)
Domain 1 - Physical 42 CFR 418.54(b)(1)Lead: RN
Primary terminal diagnosis documented
Relevant comorbidities listed
Functional status assessed (PPS or FAST score documented)PPS: ____ / 100 FAST Stage: ____
Pain severity assessed (scale documented)Pain Scale: ____ / 10 Tool used: ____________
Symptom burden assessed (nausea, dyspnea, fatigue, etc.)
Wound/skin integrity assessed
Nutrition and hydration status assessed
Fall risk assessed
Clinician completing domain:Date:
Domain 2 - Psychosocial 42 CFR 418.54(b)(2)Lead: Social Worker
Emotional status and mental health history assessed
Social support network identified (family, neighbors, community)
Caregiver identity, availability, and current capacity assessedCaregiver name: __________________________
Caregiver strain or burnout risk documented
Financial concerns or barriers identified
Prior mental health diagnoses or psychiatric history noted
Clinician completing domain:Date:
Domain 3 - Emotional 42 CFR 418.54(b)(3)Lead: SW / RN / Chaplain
Patient's response to terminal diagnosis documented
Patient's expressed fears, concerns, or unmet emotional needs documented
Family members' emotional responses and needs documented
Anxiety or depression indicators assessed
Clinician completing domain:Date:
Domain 4 - Spiritual 42 CFR 418.54(b)(4)Lead: Chaplain
Marking this domain "N/A" without documented clinical rationale is a survey citation. Every patient must have this domain assessed.
Religious affiliation or preferences identified (or none - document explicitly)
Spiritual needs and existential concerns assessed
Chaplain/pastoral care need identified and follow-up plan documented
Patient or family requests for specific religious rites or practices noted
Domain deferred - clinical rationale:
Chaplain completing domain:Date:
Domain 5 - Drug Profile Review 42 CFR 418.54(b)(5)Lead: RN / Pharmacist
Complete current medication list obtained and reviewed
Medications reviewed for therapeutic duplication
Medications reviewed for appropriateness in comfort-focused care context
Medications unrelated to terminal condition identified (triggers addendum consideration)
PRN comfort medications in place or ordered
Clinician completing domain:Date:
Domain 6 - Bereavement 42 CFR 418.54(b)(6)Lead: SW / Chaplain
Bereavement domain is for family and caregivers - not just the patient. Must be assessed at admission even if bereavement services will be provided post-death.
Family or caregiver bereavement risk level assessedLow / Medium / High: _____________
Prior bereavement history or complicated grief factors noted
Bereavement plan of care initiated or follow-up timeline documented
Primary bereavement contacts identified by name
Clinician completing domain:Date:
Domain 7 - Safety and Environment 42 CFR 418.54(b)(7)Lead: RN / SW
Home safety assessed (fall hazards, lighting, pathways)
Emergency access confirmed (address verified, 911 accessible)
Caregiver ability to manage emergencies assessed
Equipment needs assessed (hospital bed, wheelchair, O2, commode, etc.)Equipment ordered: ___________________
Medication storage and safety assessed (controlled substances, sharps disposal)
Abuse or neglect risk screening completed
Clinician completing domain:Date:

Plan of Care Completion (42 CFR 418.56(b))

Plan of care developed from comprehensive assessment findings (not from a template)418.56(b)
Plan of care individualized to this patient's diagnoses, symptoms, goals, and needs418.56(b)
All IDG disciplines reflected in the plan of care418.56(a)
Attending physician reviewed and signed plan of careAttending signature required before care is provided under the POC 418.56(b)
Plan of care in place before hospice care is provided under the POCPOC must exist before care - not retrospective 418.56(b)
Next IDG review scheduled (within 15 calendar days)418.54(c); 418.56(c)

IDG Discipline Sign-Off

Discipline / NameSignatureDateDomain(s)
RN (Assessment Lead)
Social Worker
Chaplain
Hospice Physician / Medical Director
Attending Physician
Home Health Aide (if applicable)
Educational Use Only. Not legal advice. Verify against current primary sources and your organization's policies before use.