Volunteer Progress Record

Volunteer Progress Record
Patient Name

First Name (given name, not nickname)Last Name
Date of Activity

MonthDayYear
Date
Travel Time (Round Trip): minutes + Visit Time minutes =Length of contact: minutes
*Note - if more than 1 patient is seen at the location, please divide the travel time between the number of patients.
Visit Start Time:

Hour Minutes

AM/PM Option
Visit End Time:

Hour Minutes

AM/PM Option
Round Trip Travel Time
Total Mileage:
Patient Care Activity

Activity AssistantCompanionHousekeepingRespiteOther (Specify in comment section)
Non-Patient Activity

OfficeBereavement Support CallsOther (Specify in comment section)
Safety Precautions Followed Per Plan of Care:

YesNo
Patient Appearance:
Alertness:

AwakeAsleep
Participation:

ActivePassive
Mood:

GoodFairPoor
Conversation:

AppropriateConfusedNo Response
If the patient appears to be in pain or distress or there are other concerns which should be addressed promptly please call the Hospice office at 616-846-2015.
Visit Notes (Brief description of how you spent time with your patient):
Volunteer Name

First NameLast Name
I certify that all of my responses are complete and accurate.
Signature

Clear
Mileage
Should be Empty: