Name:
Supportive Care of the Dying: Modified City of Hope Patient Questionnaire
and CALL Care Cover Letters
Description:
Two questionnaires for the patient enrolled in the CALL Care program assessing
experiences in the following areas: physical, emotional, spiritual, health care
environment, health care providers, and personal information. Includes an introductory
cover letter to the patient.
Category:
Clinical Care Tool - Clinical Assessment
Source:
Supportive Care of the Dying: A Coalition for Compassionate Care
c/o Providence Health System
4805 NE Glisan Street,2E07
Portland, Oregon 97213
tel: (503) 215-5053
fax: (503) 215-5054
www.careofdying.org
Contact:
Sylvia McSkimming
e-mail: Sylvia.McSkimming@providence.org
How the grantee used this instrument:
Used to gather information for assessment of the patient at one month, three
months, and every three months thereafter. The first, longer version of the
questionnaire was filled out at the time of enrolling in the CALL Care program.
The second version is shorter and may be used in subsequent data gathering sessions.
Only the first eight questions were mandatory.
Keywords:
symptom assessment, psychosocial assessment, health status, function, patient
experience
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.
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.
PDF 95 KB / 12 pages (Viewing
PDF files requires downloading and installation of the free Adobe
Acrobat Reader.)
Posted October 2004
# SCD03, 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 people and their families. Visit PromotingExcellence.org for more resources.
