Sharon I have been a hospice nurse for 15 years and am now a hospice educator. When I make a visit, I make sure to document all perteinet findings. I also documernt any decline in the pateint. Documentation needs to show some sort of decline if applicable, this will help when you need to recertify the patient. I document mainly on the primary diagnosis but if the co-morbitites are influecning deline than I document on that also. An example of documentation would be the patients vital signs, document delcine for example the patient is depdendent in 3 out of 6 adl's then if the pateint delcines and now needs assistance with say 5 out of 6 adl's it will be easiler to recongize the decline. I hope this helps