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
Mileage
Total Mileage:
Location of Patient
Patient Care Activity
Non-Patient Activity
Safety Precautions Followed Per Plan of Care:
On arrival, patient was
Patient Appearance:
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.
Or arrival, patient alertness
On arrival, patient alertness:
Participation:
Mood:
Conversation:
At the end of visit, patient appeared to be
Caregiver Appearance:
On arrival Caregiver appeared to be
At the end of visit Caregiver appeared to be
Visit Notes (Brief description of how you spent time with your patient):
Next scheduled contact: (approximate date/time)
Volunteer Name

First NameLast Name
Signature
Should be Empty: