HOSPICE ACTIVITY SUMMARY
STUDENT NAME: __________________________________
HOSPICE: ________________________________________
HOSPICE VISIT DATES:_____________________________
To be completed by the hospice nurse accompanying student. Please FAX to Dr. Debbie Shpritz at 410-328-2822 or return to student to turn in.
| ACTIVITY | YES | NO |
| Arrived on time for hospice experiences | ||
| Collected information from patient chart and hospice health provider for home visit | ||
| Discussed reason for patient home visit, plan of care with hospice health care provider | ||
| Participated in the care of patients as mutually determined by the student | ||
| Established a positive rapport with the patient | ||
| Utilized elements of compassionate approach when interacting with the patient and family | ||
| Identified patient problems | ||
| Discussed with hospice staff how the terminal illness has affected the family, identifies problems and interventions to meet patient and family needs. | ||
| Sought information by asking questions of the hospice staff relating to the patient, family and hospice experience |
COMMENTS: (use reverse side of page for additional space)
_____________________________________________
___________
Signature and title of hospice nurse
Date