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Run: Family Caregiver Training and Education Record (Hospice)

A hospice caregiver training record for documenting what was taught, who attended, teach-back, competency, and follow-up needs. Use it to keep plan-of-care e...

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Visit and Education Context

Patient Identifier (required)

Use the facility's internal patient identifier or medical record number. Do not enter a full SSN.

Date of Education (required)

Time of Education

Education Setting (required)

Hospice Team Member Providing Education (required)

Enter the role and name as appropriate for the audit trail.

Plan-of-Care Task Addressed (required)

Select all tasks covered during this education session.

Describe Other Task

Who Was Taught

Caregiver Relationship to Patient (required)

Caregiver Name

Optional unless needed for care coordination or local policy.

Caregiver Contact Number

Collect only if needed for follow-up education or coordination.

Number of Caregivers Taught (required)

Caregiver Present for Entire Session (required)

Education Topics and Methods

Teaching Method Used (required)

Medication Education Provided

Yes No N/A

Medication Topics Covered

Safety Topics Covered (required)

Additional Education Notes

Document any task-specific instructions, caregiver questions, or barriers to understanding.

Understanding and Competency

Teach-Back Completed (required)

Return Demonstration Completed (required)

Competency Status (required)

Caregiver Understanding Rating

Barriers to Learning

Follow-Up, Consent, and Submission

Follow-Up Education Needed (required)

Follow-Up Topics

Preferred Follow-Up Date

Consent to Document Education in the Clinical Record (required)

By checking this box, the caregiver acknowledges that the education provided may be documented in the hospice clinical record for continuity of care and audit trail purposes.

Yes No N/A

Submitter Signature (required)

Submission Notes

Use for any final clarification needed for the care team.

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Email (required)

Your name (optional)

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