BON SECOURS HOSPICE
Patient/Family Support Volunteer Visitation Report
2010
Bon Secours Hospice
3636 High Street
Portsmouth, VA 23707
&
716 Denbigh Blvd Suite B2
Newport News, VA 23603
737-2276 – Volunteer Coordinator
391-6017 – Hospice Main Number
397-6457 – Fax Number
Cairey_Williams@bshsi.org
Note: A separate form must be completed for each week.
A phone call may also be included if it occurs within the same week (Sunday through Saturday).
To ensure we meet licensing requirements, please complete form in BLACK INK and return to Hospice within 7 Days of patient contact.
Volunteer Name: ___________________________________________________________________________________________
Patient Name: _______________________________________________ Visit Frequency: _______________________________
Visit Code
Date
Round Trip
Travel Time
Visit Start Time
Visit Stop Time
Round Trip
Mileage
Duration of Visit
Hrs
Min
:
AM/PM
:
AM/PM
hrs
min
Hrs
Min
:
AM/PM
:
AM/PM
hrs
min
Hrs
Min
:
AM/PM
:
AM/PM
hrs
min
Hrs
Min
:
AM/PM
:
AM/PM
hrs
min
Hrs
Min
:
AM/PM
:
AM/PM
hrs
min
Hrs
Min
:
AM/PM
:
AM/PM
hrs
min
CODES: Volunteer: Home/facility visits VL ADMIN – Administrative, VL VISIT - Volunteer Visit, VL SP PROJ – Special
Projects, VL PHONE – Telephone Visit, VL MILEAGE- Mileage Volunteer: Bereavement Activities BR VL ADMN –
Administrative, BR VOL – Bereavement Visit, BR VL SP – Special Projects, BR VL CALL – Telephone Visit
Service(s) Provided (Check all that apply)
Respite
Transportation
Emotional Support
Errands/Shopping
Socialization
Phone Call
Reading
Journaling
Letter Writing
Life Review
Guided Imagery
Requested Prayer
Other: ___________
____________________
____________________
Volunteer notes regarding visit (not to exceed lines provided below):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
________________________________________________
Volunteer Signature
________________________________________________
Volunteer Coordinator
___________________________
Date
___________________________
Date
Bon Secours Hospice ESAS TOOL(Volunteer Note)
1) Patient Name __________________________________________________ DOB ____________________
Please circle the number that best describes:
NO PAIN
_________________________________________________ Worst Possible Pain
0
1
2
3
4
5
6
7
8
9
10
NO SHORTNESS _________________________________________________ Worst Possible Shortness of Breath
OF BREATH
0
1
2
3
4
5
6
7
8
9
10
Completed By (check one)
Patient Alone
Patient w/Caregiver
Patient w/Healthcare Professional
Caregiver Alone
Healthcare Professional Alone
If pain or shortness of breath is 4 or greater, was treatment initiated within 4 hours?
YES
NO
Asked Patient/Caregiver when the last dose of medications were administered. Time: ______________
Contacted Hospice or Volunteer Coordinator to initiate action.
Was the Patient/Family satisfied with treatment?
YES
NO
Note ______________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Date & Time of Visit _________ ________________________________________________________________
Volunteer Signature _________ ________________________________________________________________
2) Patient Name __________________________________________________ DOB ____________________
Please circle the number that best describes:
NO PAIN
_________________________________________________ Worst Possible Pain
0
1
2
3
4
5
6
7
8
9
10
NO SHORTNESS _________________________________________________ Worst Possible Shortness of Breath
OF BREATH
0
1
2
3
4
5
6
7
8
9
10
Completed By (check one)
Patient Alone
Patient w/Caregiver
Patient w/Healthcare Professional
Caregiver Alone
Healthcare Professional Alone
If pain or shortness of breath is 4 or greater, was treatment initiated within 4 hours?
YES
NO
Asked Patient/Caregiver when the last dose of medications were administered. Time: ______________
Contacted Hospice or Volunteer Coordinator to initiate action.
Was the Patient/Family satisfied with treatment?
YES
NO
Note: ______________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Date & Time of Visit _________ ________________________________________________________________
Volunteer Signature _________ ________________________________________________________________