Section 4
Sample of Family Meeting Record Sheet used by Milford Care Centre and Marymount University Hospital and Hospice
Family Meeting Record Sheet Date & time of meeting: ______________________ Venue: _____________________________________ Duration: ___________________________________
Patient Information Label
PRE-MEETING PLANNING Family Meeting discussed with patient Yes
No
Reasons if not discussed _________________________
Verbal consent obtained from the patient Yes
No
If not, why? ___________________________________
Patient attending: Yes
No If not, why? _______________________________________________________
Family members to attend as agreed by patient: ______________________________________________________
______________________________________________________________________________________________ Family members contacted by: ____________________________________________________________________ Purpose of Family Meeting:
Medical, Nursing, Physiotherapy update
Discussion on place of care
Discharge planning
Prognosis/End-of-life care
Other: Patient’s/family concerns: ________________________________________________________________________
Family meeting leaflet given Yes
No
Staff Present
MED: ____________________________________ NURSING: _____________________________________ PHYSIO: _______________________SW: __________________________________ OT: ____________________ Other team members attending: __________________________________________________________________ Chairperson: __________________________________________________________________________________
Hospice at Home/Home Care notified
Day Care notified
Post formal family meeting Feedback given to patient who did not attend the meeting Yes
No
By whom? _______________________
If not, why? ____________________________________________________________________________________
Family Meeting record sheet completed by _________________________________________________________
Goals achieved by Patient
Family
MDT
Is follow up meeting required Yes
No
If yes, when _____________________________________________
Staff debriefing Yes
No
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Facilitating discussions on future and end-of-life care with a person with dementia
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