Promoting Excellence : C3Change Care Tool

Name:
Children's Hospital: C3Change Care Tool

Parent Report for Children Ages 0-4
Provider Report for Children Ages 0-4
Patient Report for Children Ages 5-7
Patient Report for Children Ages 8-21
Parent Report for Children Ages 5-21
Provider Report for Children Ages 5-21

Definition:
These surveys assess the symptoms and emotional and social well being of children with life-limiting illnesses.

Category:
Clinical Care Tools - Clinical Assessment

Source:
Children's Hospital and Regional Medical Center
Pediatric Palliative Care Project
Mail Stop CM - 11
4800 Sand Point Way, N.E.
Seattle, WA 98105
www.cshcn.org

Contact:
Beth McKinstry
bmckin@chmc.org

How the grantee used this instrument:
Self-administered by parent and/or patient with in-person assistance from Consultant at the pre-enrollment home visit, or agency case manager on a per request basis. Self-administered by physician at or immediately after the enrollment clinic visit. Parent and/or patient responds to telephone interview every three months.

Keywords:
pediatrics, emotional well-being, psychosocial assessment

To use this tool:
You may print and copy this tool for your own use from this site. Please credit source.

References:
Developed specifically for this project by the project team with input from a parent focus group.

Information/References on Validity and Reliability:
Measures pain and symptoms for children with life-limiting illnesses and includes spiritual and quality of life domains.

To view this tool:
Left click on the download link to view the PDF document in your Web browser. Right-click on the download link to save the document to your computer. (Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.)

Parent Report for Children Ages 0-4 PDF 419 KB / 8 pages
Provider Report for Children Ages 0-4 PDF 421 KB / 8 pages
Patient Report for Children Ages 5-7 PDF 320 KB / 8 pages
Patient Report for Children Ages 8-21 PDF 413 KB / 8 pages
Parent Report for Children Ages 5-21 PDF 416 KB / 8 pages
Provider Report for Children Ages 5-21 PDF 417 KB / 8 pages

Posted September 2003

Children's Hospital and Regional Medical Center overview page

# CHRMC8, type:clinical_assessment

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.