Volunteer Progress Record

Volunteer Progress Record
Patient Name

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

Month Day Year
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 Assistant Companion Housekeeping Respite Other (Specify in comment section)
Non-Patient Activity

Office Bereavement Support Calls Other (Specify in comment section)
Safety Precautions Followed Per Plan of Care:

Yes No
Patient Appearance:
Alertness:

Awake Asleep
Participation:

Active Passive
Mood:

Good Fair Poor
Conversation:

Appropriate Confused No 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 Name Last Name
I certify that all of my responses are complete and accurate.
Signature

Clear
Mileage
Should be Empty: