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Hospice

Volunteer Visit Note

VOLUNTEER INFORMATION
Volunteer Name:
Assignment Date:
Start Time:
End Time:
ASSIGNMENT LOCATION:
ADMINISTRATIVE SUPPORT
Clerical Support Provided
Clerical Answer phones Make packets Filing
Other:
Bereavement Support Provided
Phone support Mail letters Attend funeral Support group
Other:
PATIENT CARE SUPPORT
Patient Name:

Patient Care Support Provided
Companionship Emotional support Caregiver respite Went to activities
Read Talked Watched TV Went for a walk
Music therapy Pet therapyOther:
When I made my visit, the patient was (Check all that apply)
Up in a chair In a wheelchair In bed Sleeping Awake Alert
Unresponsive Drowsy Appeared cheerful Appeared sad Confused
Patient having unrelieved symptoms?
Time:
Case Manager notified?
Case Manager Name:
PROGRESS NOTES / SUMMARY