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Run: Hospice Bereavement Assessment and Follow-Up Plan

A hospice bereavement assessment and follow-up plan form for documenting family grief needs, consent, and a written support plan that continues for at least ...

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Patient and Death Record

Patient Record ID (required)

Use the hospice record identifier only; do not enter SSN or other unnecessary PII.

Date of Death (required)

Bereavement Follow-Up Start Date (required)

Typically the date bereavement services begin after death.

Bereavement Coordinator (required)

Name or role of the staff member responsible for the plan.

Bereaved Person and Consent

Bereaved Person Name (required)

Enter the primary bereaved contact's name.

Relationship to Patient (required)

Preferred Contact Method (required)

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 (required)

Document consent for outreach and support services. If no direct contact is preferred, document that preference here.

Yes No N/A

Bereavement Needs Assessment

Current Grief Response (required)

Primary Support Needs (required)

Bereavement Risk Factors Present? (required)

Risk Factors (required)

Signs of Complicated Grief Concern? (required)

Use clinical judgment to identify persistent or severe grief reactions that may need referral.

Assessment Summary (required)

Summarize the bereavement needs assessment, including observed needs, strengths, and any referral considerations.

Written Follow-Up Plan

Follow-Up Duration (Months) (required)

Must be at least 13 months to meet hospice bereavement follow-up expectations.

Follow-Up Frequency (required)

Planned Contact Methods (required)

Support Services Planned (required)

Referral to Additional Services Needed? (required)

Referral Details (required)

Describe the referral destination, reason, and any follow-up responsibility.

Follow-Up Schedule and Audit Trail

Follow-Up Schedule (required)

Plan and track bereavement contacts over the follow-up period.

Next Review Date (required)

Audit Trail Notes

Record any changes to the plan, missed contacts, or significant updates for compliance tracking.

Submission and Confirmation

Bereavement Plan Complete (required)

Yes No N/A

Submitted By (required)

Submission Date (required)

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