Bereavement Assessment

[comment memo="BEREAVED INFO"]
NAME: [text name="name" size="20"] RELATIONSHIP: [text name="relationship" size="20"] 
GENDER [radio name="gender" value="male|female"]
[conditional field="gender" condition="(gender).is('male')"][text name="possessive" default="his" size="3"][text name="subjective" default="he" size="3"][text name="objective" default="him" size="3"][/conditional][conditional field="gender" condition="(gender).is('female')"][text name="possessive" default="her" size="3"][text name="subjective" default="she" size="3"][text name="objective" default="her" size="3"][/conditional]


-------------------------- copy following text -------------------------------

[comment memo="PURPOSE"]
[select name="PURPOSE" value="Initial Condolence t/c;|Bereavement Assessment t/c;|Bereavement Well-Being t/c;|Bereavement t/c Message;|Bereavement t/c Attempt;|Bereavement Well-Being Visit;|Bereavement Activity;"]
Bereavement activity with [var name="name"], pt's [var name="relationship"][checkbox name="condolences" value=", extending sympathy and exploring bereavement needs"].
[checkbox memo="COMMUNICATION" name="COMMUNICATION" value=""][conditional field="COMMUNICATION" condition="(COMMUNICATION).is('')"][var name="name"] [checkbox name="COMMSTYLE" value="expressed thoughts and emotions with ease throughout t/c.|was reserved in communicating thoughts and emotions throughout t/c.|was tearful and expressed emotions with clarity and precision throughout t/c.|was able to converse without difficulty throughout t/c.|Conversational guidance was provided to facilitate open communication throughout t/c.|Conversational guidance was provided for the bereaved who was reserved in communication throughout t/c."][/conditional]
[checkbox memo="COPING" name="COPING" value=""][conditional field="COPING" condition="(COPING).is('')"][var name="name"] [checkbox name="COPINGSTATEMENT" value="When asked how she has been coping, ________ confidently stated,"][/conditional][checkbox memo="MEMORIAL" name="MEMORIAL" value=""][conditional field="MEMORIAL" condition="(MEMORIAL).is('')"][checkbox name="MEMORIALPLANS" value="the family is not planning to have a memorial at this time|the family plans to have a memorial at a later date|the family is planning to have a memorial service"][/conditional]
[checkbox memo="INTERVENTIONS" name="INTERVENTIONS" value=""][conditional field="INTERVENTIONS" condition="(INTERVENTIONS).is('')"][var name="name"] [checkbox name="INTPROVIDED" value="Support and Active Listening were provided|Education regarding grief process was provided|was normalized|Space for Reminiscence and reflection was provided|Space for reflection and introspection was provided"][/conditional]
as the pt's [var name="relationship"] stated _________
[checkbox memo="SUPPORT" name="SUPPORT" value=""][conditional field="SUPPORT" condition="(SUPPORT).is('')"][var name="name"] [checkbox name="STATEDSUPPORT" value="|"][/conditional]
as the pt's [var name="relationship"] stated _________
[checkbox memo="ROUTINE" name="ROUTINE" value=""][conditional field="ROUTINE" condition="(ROUTINE).is('')"]
[var name="name"] expressed [select name="ACTIVITIES" value="returning to routine of|normal patterns of eating and sleeping.|verbalized no change in eating and sleeping patterns.|articulated with great detail daily routine, which appears to evince reconstructive behaviors."]
[/conditional]
[checkbox memo="APPRECIATION" name="APPRECIATION" value=""]
[conditional field="APPRECIATION" condition="(APPRECIATION).is('')"][var name="name"] [checkbox name="APPRECIATIONEXPRESSED" value="gave appreciation for the hospice team’s involvement during the decedents end of life|||"][/conditional]
as the pt's [var name="relationship"] stated _________ [checkbox memo="ASSESSMENT" name="ASSESSMENT" value=""]
[conditional field="ASSESSMENT" condition="(ASSESSMENT).is('')"][var name="name"] appears to be [select name="variable_1" value="grieving appropriately|struggling etc|in danger etc"] and appears to be a [select name="RISK" value="low bereavement risk|moderate bereavement risk|high bereavement risk"] at this time.
[/conditional]
[checkbox memo="CAREPLAN" name="CAREPLAN" value=""]
[conditional field="CAREPLAN" condition="(CAREPLAN).is('')"]
[checkbox name="FUTUREINTERVENTIONS" value="Well-being t/c scheduled for ___________ from the time of this writing.|BC made several attempts to contact the PCG of the patient. Bereavement program was explained, including support calls and mailings. A letter will be sent outlining these same programs.|Multiple attempts to reach PCG of the pt were made unsuccessfully. A letter will be sent outlining Bereavement services with mailings through _________ |Well-being t/c scheduled for ___________ from the time of this writing."][/conditional]

[checkbox memo="MESSAGE" name="MESSAGE" value=""]
[conditional field="MESSAGE" condition="(MESSAGE).is('')"] 
[checkbox name="FUTUREINTERVENTIONS" value="Well-being t/c scheduled for ___________ from the time of this writing.|BC made several attempts to contact the PCG of the patient. Bereavement program was explained, including support calls and mailings. A letter will be sent outlining these same programs.|Multiple attempts to reach PCG of the pt were made unsuccessfully. A letter will be sent outlining Bereavement services with mailings through _________ |Well-being t/c scheduled for ___________ from the time of this writing."]
[/conditional]
BEREAVED INFO
NAME: RELATIONSHIP:
GENDER



-------------------------- copy following text -------------------------------

PURPOSE

Bereavement activity with name, pt's relationship .
COMMUNICATION
COPING MEMORIAL
INTERVENTIONS
as the pt's relationship stated _________
SUPPORT
as the pt's relationship stated _________
ROUTINE
APPRECIATION

as the pt's relationship stated _________ ASSESSMENT

CAREPLAN


MESSAGE

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.75, 58 form elements, 24 boilerplate words, 8 text boxes, 19 checkboxes, 1 radio buttons, 4 drop downs, 12 variables, 2 comments, 12 conditionals, 53 total clicks
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