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    Contoh Formulir Pelayanan Kerohanian RS

    Uploaded by

    Prima Rahmadhany
    Yan Roh

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Contoh Formulir Pelayanan Kerohanian RS

    Uploaded by

    Prima Rahmadhany
    17 views2 pages
    Yan Roh

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

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    Yan Roh

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    17 views2 pages

    Contoh Formulir Pelayanan Kerohanian RS

    Uploaded by

    Prima Rahmadhany
    Yan Roh

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    Spiritual Care Advance Directive for

    ______________________________________
    To encourage, facilitate, & authorize the partnership of care
    between my health care providers& my faith community/spiritual
    care providers and in order to receive appropriate and
    timely spiritual care, I voluntarily request and authorize my doctor
    and/or the staff of
    _____________________________________________________________________________
    (Name of health care organization, health care provider(s) and/or senior living
    facility)
    to notify my faith community or spiritual provider named below as soon as
    reasonably possible in theevent of one of the following as initialed by me, my
    next of kin, or legal representative and
    to share
    with them the medical information (PHI) needed to determine appropriate
    spiritual care for me.
    _____ if I am admitted to a hospital
    _____ if I am sent to a hospital emergency department
    _____ if I am transferred to another health care facility
    _____ if I (or my family) have been informed of significant changes to
    my mental or physical health
    _____ if I (or my family) have been informed that end of life
    treatment options need to be discussed
    _____ if I (or my family) have been informed that it appears I am
    near death
    _____ upon my death
    _____ at my, my family, or legal representatives request
    _____Other:_________________________________________________________________
    __ I understand I may amend or revoke the above at any time in writing. I
    agree to hold harmless the facility(ies) named in this document and their staff
    and my doctor(s) if for any reason they fail to initiate the notifications
    authorized above.
    Signed ____________________________________________________Date:____________
    ____
    Or, signed on behalf
    of_________________________________________________________________________
    By__________________________________________________________________Date:________________
    ___
    Relationship;____________________________________________________________________________
    _____

    I revoke this Advance


    Directive:___________________________________________Date:____________________
    Witnessed by or confirmed by (Health Care Provider or Organizational
    Representative Signature/Title)
    _________________________________________________________Date:______________
    _
    Faith Community Name : _______________________________________________Phone
    #:_________________
    Spiritual Care Provider(s) Name(s), Phone #s & Email Addresses:
    _____________________________________________________________________________
    ______________________________________________________________________________
    Or, the current Spiritual Provider for the faith community named above.
    Please note
    the faith community and its care providers are NOT to make public or disclose
    the informationprovided by my health care providers to others without my
    further consent, or if I am unable, the consent of mynext of kin or legal
    representative.Copy: __ for oneself __ family __ for the health care provider __
    for faith community/provider
    Please review the Information and Instruction page before
    completing this form.

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