Volunteer: Patient Visit Report Volunteer Name*Pt ID#*Confirm Pt ID#*Date of Service* Date Format: MM slash DD slash YYYY Visit Start Time (Please enter time in 15 minute increments, on the quarter hour. Example: 2:15, 2:30, 2:45)* : HH MM AM PM Visit End Time (Please enter time in 15 minute increments, on the quarter hour. Example: 2:15, 2:30, 2:45)* : HH MM AM PM Round Trip Travel Time*Type of VisitStandard VisitTelephone CallRelief of Primary CaregiverCaring PresenceCaregiver CompanionMusic & MemoryHaircutLife ReviewPet SupportPet TherapyVeteran SupportFirst Visit Identifiers (FIRST VISIT ONLY - please select either “Home” or “Facility,” then select all that apply in the fields below)HomeFacility- Home Asked Pt/pcg to confirm Pt name Asked Pt/pcg to confirm Pt date of birth - Facility Made first visit with HOCO team member Asked facility staff to escort me to Pt room/location and introduce me Observations (check all that apply) No direct Pt communication Comfortable appearance Confused appearance Alert appearance Uncomfortable appearance (describe below in comments) Activity (check all that apply) Light housekeeping Provide Socialization Comments (text box will appear) CommentsMissed VisitYou must notify a member of your patient care team when you are unable to visit your Pt, by voicemail, email, or text.Illness (please explain briefly)Other (please explain briefly)Illness reasonOther reasonI hereby esign this form by entering my name below* This iframe contains the logic required to handle Ajax powered Gravity Forms.
