Spiritual Care / Chaplain Visit
Method of contact
Visit
Phone
Refused
Location of visit:
Client's residence
Living facility
Other
Person(s) Present during visit
General Appearance
Patient's pain level:
Client/Primary Caregiver report no pain
Client/Primary Caregiver report pain within acceptable range
Client/Primary Caregiver report pain outside of acceptable range
phone call to Hospice at: (time)
Spiritual Needs or Concerns
Alienation
Fear
Guilt
Shame
Despair
Helplessness
Hopelessness
Need for reconciliation
None identified
Other
Interventions / Support offered
Type of follow-desired
Practice
Person
N/A
Brief summary of visit (maximum 125 words)
Volunteer Name
Contact Date
/
Month
/
Day
Year
Date
Time: From
Hour Minutes
AM
PM
AM/PM Option
Time: To
Hour Minutes
AM
PM
AM/PM Option
Travel Time:
I wish to be reimbursed for mileage
Yes
No
Mileage
Total Sp. Care Volunteer Time: (Visit time + Travel time) Please include for every visit.
Client Name
Client Number
Spiritual Care / Chaplain Visit Record 02.10.21
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