Type of Assignment:   Patient/Family Care Grief Support

Clinical Record Number:     

Patient Name:      (First name only please)

Date of Visit or Phone Call:

Description of Visit including:

• The nature of the interaction with the patient and caregiver including activities, etc. 
• Any evidence of decline in patient condition.
• Communication with the team including who you spoke with, their discipline (RN, social worker, chaplain, volunteer services, etc.) and reason for communication.

Additional Information for Volunteer Services
T this information will not be included in the patient clinical record. Please include things like, upcoming scheduling changes, questions or requests for additional information.

Total Time Spent

Mileage:

Volunteer Name: