Don't expect reviewers and surveyors to be satisfied with vague clinical notes. In addition to the patient's vital signs, the patient's record should include these types of clinically measurable data points that show the patient's decline is consistent with a six month or less prognosis,according to consultant • Body mass index • Mid-arm or mid-thigh circumferences • Palliative performance scale scores • Functional assessment staging scores • Infection history • Physician office or emergency room visits • Increasing levels of caregiver support with activities of daily living (ADLs) • Increasing frequency of hospice visits, changing medical equipment, or medication-related needs.