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

Field	Details
Evaluation Date:
Resident:
Room Number:

Rating Scale

Score	Meaning	Details
1	Poor	Performance significantly below expectations, requiring substantial improvement.
2	Below Average	Performance below expectations, with notable areas needing improvement.
3	Average	Performance meeting basic expectations, with room for improvement in some areas.
4	Above Average	Performance consistently meeting or exceeding expectations, with minor areas for improvement.
5	Excellent	Exceptional performance consistently exceeding expectations, demonstrating high proficiency.

Evaluation

Aspect	1	2	3	4	5
Pain Management
Emotional Support
Communication
Family Involvement
Comfort and Dignity
Spiritual and Cultural Needs
Staff Compassion and Empathy
Bereavement Support
Overall Satisfaction
Total Score

Additional Comments/Suggestions

No.	Comments/Suggestions
1.
2.
3.
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].

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