This form is intended for Patient / Family volunteers who cannot come into the office to log their service time.

Medicare regulation requires that all communication and contact with patients and families be documented, so thank you for helping us stay compliant.

IMPORTANT: Please do not include any Names, Addresses, or other specific identifying information in your report, as this would be a HIPPA violation. Instead, use the patient medical record number found in the top left corner of the face sheet, and use acronyms like, PT, Hus, Dau, BIL, PCG.

For issues or concerns that require immediate attention from the patient's nurse. DO NOT wait to report this in a service report, call our office immediately.  256-650-1212 (day or night).
When selecting Goal(s) for Visit:
- Companion - Use when the primary focus for the visit is to support the patient's needs for social and emotional support.
- Skilled - Use when you're providing skilled services like haircuts, or if you have a professional license like, RN, CNA, and we asked you to work in that capacity.
- PCG Support - Use when the primary focus of the visit is to support the primary caregiver (PCG).  Examples: extended visits so the PCG can leave or social/emotional support for the PCG.
- Errands/Chores - Use when doing light housekeeping, lawn care, shopping, picking groceries, etc.
- Reduce Pain/Agitation/Boredom - Only use if VC told you this was a goal. Activities may be hand massages, crafts, or other distractions instead to reduce fixation on pain. Otherwise these activities are for companionship.
- BVT Call / Visit - Use this if you are providing bereavement support. Examples: Calling or visiting family after patient dies, sending a sympathy card, attending a viewing or funeral.
- Vigil Support - Use if you're sitting vigil or supporting the patient/family with creating a transition plan or doing legacy work.

If you have any questions, please do not hesitate to contact the Volunteer Coordinator.
Date of Visit / Call*
Volunteer's Name*
Pt's Medical Record # (B-XXXXX)*
Total Travel Time (To & From):*
Total Service Time (include calls and visit time)*
Total Mileage (To and From):*
Type of Service*
Goal(s) for Visit*Companion   Skilled   PCG Support   
Errands/Chores   Reduce Pain/Agitation/Boredom   BVT Call/Visit   
Vigil Support   
Narrative of Patient Visit*
Next Scheduled Visit:*
Any Additional Notes about Your Experience*