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Volunteer Resources: Visit Note Form

Hospice Volunteer Visit Note

 
 
 
 
 
 
 

Total Volunteering Time

Please include the time you spend:

  • Preparing for and traveling to/from your visit
  • Communicating with your volunteer coordinator and patient caregivers
  • Submitting your activity log

Do not include travel time when your visit is over the phone.

 
 
Patient was (check all that apply)
Sleeping
Awake
Alert
Confused
Peaceful
In pain
Agitated
 
 

Please note the activities you supported to improve the patient's quality of life and how the patient responded to those activities. For example, Bible reading, transportation, shopping, etc.

Change of Patient Condition (required)
Improvement observed
Decline observed
No change observed
 
 

Answer this question: what is the patient's functional condition compared to your previous visist? Consider patient's food intake, walking (distance, steadiness, etc.), awareness, energy, confusion, and communication.

 
 
By checking this box: (required)
I certify that this is my electronic signature and that I am authorized to submit this information
 
By checking this box: (required)
I certify to the best of my knowledge that there is no identifying Protected Health Information included in this submission