Bereavement Follow-Up Contact Note (Hospice/Community)

Contact Date/Time: [Date and time of contact]

Author: [Author name], [Credentials], [Role/Discipline]

Modality: [phone / video / in-person / letter / voicemail]

Contact Status: [reached / left message / no answer / letter sent / declined]

Duration: [Minutes, or "N/A" if not applicable]

Contact Context

(Include only minimal decedent details needed to contextualize bereavement services.)

• Decedent: [Name], [Date of death]
• Bereaved Person: [Name], [Relationship to decedent]
• Time Since Death: [Explicit duration, e.g., "6 weeks post-death"]
• Reason for Contact: [scheduled follow-up per plan / bereaved person initiated / crisis outreach / anniversary outreach]
• Prior Contact Summary: [Last contact date and key takeaway, or "Initial contact"]

Assessment

(Include only if contact was successful and person engaged. Attribute information as reported versus observed. Use "Not assessed due to [reason]" if unable to assess.)

[Current grief presentation: primary grief experiences, functional impact on ADLs/work/social engagement, sleep and appetite, mood symptoms, support system, and relevant spiritual or cultural context] (Use 1–2 concise paragraphs. Include direct quotes sparingly for key statements such as refusals, goals, or concerning statements.)

Risk & Safety

(Required for all successful contacts. If contact was unsuccessful, state "Unable to assess—no contact made" and note any escalation per protocol for high-risk individuals.)

• Suicidal ideation/self-harm: [yes / no] (If yes, document ideation, plan, intent, and access to means.)
• Protective factors: [At least 1–2: e.g., children, faith, supportive relationships, reasons for living]
• Risk level: [low / moderate / high] — [Brief justification]
• Actions taken if elevated: [Safety planning, crisis resources provided, supervisor notified, shortened follow-up interval, warm handoff] (Document whether bereaved person agrees with plan; if refused, note refusal and escalation steps.)

Interventions & Plan

(Include for successful contacts. If services declined, document decline, offer re-entry pathway, and note whether future outreach continues or is paused.)

• Interventions provided: [Supportive listening / grief education / coping strategies reviewed / resources provided / bereavement program offerings discussed] — [Response/engagement level]
• Next Contact: [Target date range and modality]
• Tasks: [Mail resources / coordinate referral / other pending items]
• Referrals: [Internal or external referrals, with consent noted]
• Crisis Resources: [Confirm crisis line information provided per policy]

Unsuccessful Contact Attempt

(Use instead of Assessment, Risk & Safety, and Interventions & Plan when bereaved person was not reached.)

• Attempt: [e.g., "Attempt 2 of 3"]
• Result: [no answer / voicemail left / wrong number / returned mail]
• Message: [Confirm no PHI disclosed in voicemail or letter per policy]
• Next Attempt: [Planned date range and alternate methods if applicable]
• Escalation: [If high-risk on file, document protocol followed; if not high-risk, note standard follow-up cadence]

Electronic Signature:
[Author name], [Credentials] — [Discipline/Role]
[Date/Time signed]