My agency taught me, that we always chart to the decline. So if you see a pt who is bright and alert that particular day, also include that this is the first time in the past 3 days or that the alert day is an exception to the pts norm. The other phrase they also refer to with charting is "why hospice, why now", to show the need for hospice services and what is going on to show the 'now'. IE: Ms. Smith ate 75% of two meals today, continues with weight decrease r/t usual intake of less than 25%.
