Chaplain Care Notes
Routine
PRN
Patient Name:
HHC#:
Visit Date:
Time:
Length of Visit:
Location:
Home
Nursing Home
Assisted Living
Inpatient Unit
Other
Visit with:
Patient
Spouse
Son
Daughter
Other
Family:
Present
Spiritual/grief needs discussed
Decline to discuss spiritual needs at this time
Not present
Follow up telephone call placed to family
Date/Time
Name
Outcome Reference:
Anticipatory Grief (C701)
Scope of Service/Support System (C505)
Spiritual (A205)
Other
Spiritual Support provided to above individual(s) through:
prayer
scripture reading
hymn singing
last rites
review near death awareness
friendship
facilitate family communication
devotionals
unresolved issues
resolved issues
review assurance of faith
explore feelings and issues
encourage life review
Other
Additional Needs/Comments:
Plan:
Continue to offer spiritual support and patient/family in agreement with care plan
Will increase or decrease frequency of visits due to
Other
Chaplain
Name:
Date: