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: POM@nhpco.org.
SECTION A: CONTACT INFORMATION
A1. NHPCO DART ID __________
A2. Hospice Full Name ________________________________
A3. State ______
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
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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