Hospice Bereavement Assessment and Follow-Up Plan

Documents a hospice family bereavement needs assessment and the written follow-up plan provided for at least 13 months after death.

Patient and Death Record

• Patient Record ID
  Use the hospice record identifier only; do not enter SSN or other unnecessary PII.
• Date of Death
• Bereavement Follow-Up Start Date
  Typically the date bereavement services begin after death.
• Bereavement Coordinator
  Name or role of the staff member responsible for the plan.

Bereaved Person and Consent

• Bereaved Person Name
  Enter the primary bereaved contact's name.
• Relationship to Patient
• Preferred Contact Method
• Contact Information
  Provide only the contact detail needed for the selected method. Leave blank if no direct contact is preferred.
• Consent for Bereavement Follow-Up
  Document consent for outreach and support services. If no direct contact is preferred, document that preference here.

Bereavement Needs Assessment

• Current Grief Response
• Primary Support Needs
• Bereavement Risk Factors Present?
• Risk Factors
• Signs of Complicated Grief Concern?
  Use clinical judgment to identify persistent or severe grief reactions that may need referral.
• Assessment Summary
  Summarize the bereavement needs assessment, including observed needs, strengths, and any referral considerations.

Written Follow-Up Plan

• Follow-Up Duration (Months)
  Must be at least 13 months to meet hospice bereavement follow-up expectations.
• Follow-Up Frequency
• Planned Contact Methods
• Support Services Planned
• Referral to Additional Services Needed?
• Referral Details
  Describe the referral destination, reason, and any follow-up responsibility.

Follow-Up Schedule and Audit Trail

• Follow-Up Schedule
  Plan and track bereavement contacts over the follow-up period.
• Next Review Date
• Audit Trail Notes
  Record any changes to the plan, missed contacts, or significant updates for compliance tracking.

Submission and Confirmation

• Bereavement Plan Complete
• Submitted By
• Submission Date