Hospice Spiritual Assessment

Chaplains and spiritual carers record each encounter with a patient and their family. They mark the kind of support given, describe family ties, faith community and personal interests, and set out a plan for continued accompaniment. The signed note joins the interdisciplinary record.

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Date

Type of contact

In-person visit Phone call Video call Family meeting

Patient Name

Nombre

Apellido

Representative or legal guardian name

Nombre

Apellido

Contact Number

Emotional support

Active listening Presence and companionship Encouragement Support with anxiety Life review

Spiritual or religious care

Prayer Scripture reading Sacraments or rites Meditation or silence Visit from a religious leader

Advocacy, referral and ethics

Referral to their faith community Ethics committee consultation Support with advance directives Link to community resources Advocacy with the care team

Loss and adjustment

Anticipatory grief Bereavement support Coping with change Planning a farewell or memorial Family conflict mediation

Family

Faith community

Work

Interests

Other

Spiritual care plan

Notes

Name of chaplain

Nombre

Apellido

Signature of chaplain

Sign here

Date

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