Hospice Bereavement Risk Assessment and Plan of Care (Family)

Note Type: Hospice Bereavement Risk Assessment and Plan of Care (Family)

Document Status: [Initial Assessment / Update / Post-Death Activation / Reassessment / Closure]

Date/Time: [Date and time]

Encounter Modality: [phone / in-person / video / mail / group / collateral review]

Author: [Name, credentials, discipline]

Deceased Patient: [Name, MRN]

Bereaved Person ID: [ID if applicable]

Reason for Note: [initial risk assessment / scheduled review / after-death outreach / significant change / escalation / referral coordination / closure]

Individuals Assessed and Permissions

(Repeat for each bereaved person included in the plan of care. If information is missing, document "Unknown—plan to obtain" with timeframe.)

• Full name: [Name] | Relationship to patient: [Relationship]

  Preferred name/pronouns: [If relevant] | Primary language: [Language] | Interpreter needed: [Yes / No]

  Contact information: [Phone, email, address]

  Preferred contact method and safe voicemail guidance: [Method and any safety/privacy instructions]

  Consent to contact and leave messages: [Granted / Limited / Declined] (Specify scope and restrictions)

  Key supports: [Emergency contact, existing therapist/PCP if consented, other supports]

Clinical Context of the Loss

[Brief narrative context relevant to bereavement support] (2–6 sentences: patient status, date of death if applicable, expected vs unexpected, setting of death, bereaved person's caregiving role/burden, and salient circumstances influencing bereavement. Exclude unrelated clinical history.)

Information Sources and Data Quality

• Information sources: [Bereaved individual(s) / patient (pre-death) / family / hospice team / chart review / other]
• Reliability limitations: [Cognitive impairment / language barrier / limited contact / third-party report / none identified]
• Dates of last direct contact: [List by individual and date]
• Unassessed domains: [Domains not assessed, barriers encountered, and time-bound plan to reassess] (Omit if all domains assessed)

Bereavement Risk Assessment

Presenting Grief Response

[Summary of current grief response] (Pre-death: anticipatory grief themes, preparation concerns, caregiving distress. Post-death: immediate grief response, functional impact, predominant emotions, coping strategies. Distinguish reported information from clinician observations.)

Psychosocial and Behavioral Health History

[Relevant history] (Prior depression/anxiety/PTSD, counseling/psychiatric treatment, substance use concerns, prior suicidal ideation/attempts. Include minimal necessary detail tied to bereavement relevance.)

Prior Losses and Family Factors

[Prior significant losses and family dynamics] (Unresolved grief indicators, family conflict/estrangement, relationship quality with deceased, practical stressors including financial, housing, legal/estate, employment.)

Supports and Protective Factors

[Support network and strengths] (Quality and availability of supports, faith/community involvement, access to practical help, individual strengths, and access to care including existing providers, transportation, technology.)

Spiritual and Cultural Considerations

[Beliefs, rituals, and norms] (Cultural norms around death/mourning, help-seeking preferences, spiritual practices/rituals, spiritual distress indicators.)

Children or Vulnerable Dependents

[Impacted dependents] (Include only if applicable: children/adolescents or other vulnerable dependents, developmental considerations, caregiver capacity, and needs for pediatric grief or related services. If none, state "None identified.")

Safety Screening

[Safety assessment findings] (If no concerns: concise negative screen. If concerns present: specific findings, immediate actions, escalation, referrals, and follow-up timeframe.)

Risk Stratification and Rationale

Risk Level: [Low / Moderate / High]

Assessment Timing: [Pre-death / Post-death]

Tool Used: [Tool name and score/category, or "Clinical judgment only"]

[Rationale for risk assignment] (3–6 sentences: top 3–5 risk factors, protective factors moderating risk, and implications for service intensity. Avoid formal psychiatric diagnoses unless qualified and criteria clearly met.)

Prioritized Needs

(List needs in order of urgency.)

• Problem statement: [Concise statement in plain language]

  Supporting evidence: [Reported and/or observed data]

  Modifiability: [Hospice-modifiable / External referral needed / Both]

Bereavement Plan of Care

(Create an individualized plan for each prioritized need. Align intensity and frequency with risk level.)

[Need title]

Goals: [Behavioral, observable, time-framed goals]

Interventions:

• [Intervention type] — Status: [offered / accepted / declined]; Barriers: [If any]

Outreach Schedule:

• Pre-death contacts: [Frequency] (Include only if patient living)
• Immediate post-death condolence: [Timing and method]
• Early phase (first weeks): [Frequency]
• Stabilization phase (1–3 months): [Frequency]
• Anniversary/holiday planning: [Approach and timing]
• Ongoing follow-up: [Frequency through service period]
• Escalation triggers: [Missed contacts, worsening function, safety concerns, requests for increased support]

Responsible Parties: [Discipline responsible for each intervention and IDT communication plan]

Plan Review and Updates

(Include only for updates or reassessments.)

• Date and reason for review: [Scheduled review / Change in condition / Other]
• Updated risk level: [Low / Moderate / High / Unchanged] — Rationale: [If changed]
• Plan changes: [Services, frequency, referrals, or goal updates]
• Coordination/handoff: [IDT communication, referrals initiated, handoffs completed]
• If services declined: [Education provided and re-offer plan with timeframe]

Closure Summary

(Include only when closing bereavement services.)

• Date and reason for closure: [Completed bereavement period / Declined further contact / Transferred to community care / Unable to contact]
• Final risk level: [Low / Moderate / High]
• Services delivered: [High-level summary]
• Goals status: [Met / Partially met / Not met] (Brief rationale)
• Resources provided: [Ongoing support resources]
• Re-contact instructions: [How to re-engage with hospice bereavement program]