Free Nursing Home End-of-Life Care Evaluation Template
Nursing Home End-of-Life Care Evaluation
Please take a few minutes to complete this evaluation form. Evaluate each aspect of end-of-life care on a scale of 1 to 5, by checking the box that corresponds to your response. Include additional comments as needed. Your responses will remain confidential and will only be used for evaluation and quality improvement purposes.
Evaluation Details
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Field |
Details |
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Evaluation Date: |
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Resident: |
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Room Number: |
Rating Scale
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Score |
Meaning |
Details |
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1 |
Poor |
Performance significantly below expectations, requiring substantial improvement. |
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2 |
Below Average |
Performance below expectations, with notable areas needing improvement. |
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3 |
Average |
Performance meeting basic expectations, with room for improvement in some areas. |
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4 |
Above Average |
Performance consistently meeting or exceeding expectations, with minor areas for improvement. |
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5 |
Excellent |
Exceptional performance consistently exceeding expectations, demonstrating high proficiency. |
Evaluation
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Aspect |
1 |
2 |
3 |
4 |
5 |
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Pain Management |
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Emotional Support |
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Communication |
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Family Involvement |
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Comfort and Dignity |
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Spiritual and Cultural Needs |
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Staff Compassion and Empathy |
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Bereavement Support |
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Overall Satisfaction |
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Total Score |
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Additional Comments/Suggestions
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No. |
Comments/Suggestions |
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1. |
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2. |
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3. |
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4. |
Thank you for taking the time to provide feedback on our end-of-life care services! If you have any further comments or concerns, please feel free to contact [Your Company Email] at [Your Company Number].
