HOME HEALTH RN CASE MANAGER COMPETENCY/SUPERVISORY VISIT FORM |
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Pre-Visit Review and Preparation: On-Site Observations
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Yes No NA Patient consents, Authorizations
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Yes No NA Medication Profile Reviewed
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Yes No NA Allergies noted on Med Profile
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Yes No NA POC, Verbal Orders Reviewed
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Yes No NA Copy of Patient Consents in Home Folder
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Yes No NA Home Folder Confidentiality
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Yes No NA Med. Profile in home reviewed for congruency
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Yes No NA Allergies in home folder match clinical record
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Yes No NA Clinical Documentation Reviewed
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Yes No NA Appropriate Teaching Material in Home Folder
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Yes No NA HHA/Attc Assignment Sheet Reviewed
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Yes No NA HHA/Attc Assignment Sheet in Home Folder
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Yes No NA Case Conferences/Care Coordination Present
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Yes No NA Copy of Patient Rights, Consents, ISDH Hot Line Number in Home foldere
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INFECTION CONTROL & SAFETY |
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Yes No Hand washing with liquid/foam soap or substitute at appropriate times.
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Yes No Cleans thermometer, stethoscope, and supplies between clients
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Yes No Disposes of waste properly
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Yes No NA Sharps container present
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Yes No Nurse bag placed on clean, dry surface
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Yes No Standard Precautions observed
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Yes No NA Instructed client on storage and disposal of supplies
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Yes No NA Supplies left in client's home were appropriately stored
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Yes No Demonstrated safe appropriate use of equipment
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Yes No Environmental safety assessed and appropriate instructions or referral given
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Yes No Client safety evaluated (ambulates safely with assistive device/client safe in wheelchair)
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Yes No NA Client’s DME equipment evaluated for signs of obvious malfunction (i.e., non-functioning brakes on a rolling walker)
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Yes No NA Client oxygen safety evaluated
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ADMISSION VISIT |
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The Registered Nurse explained the following:
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Yes No Home care services
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Yes No Agency expectations
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Yes No Reasonable client expectations (calling to cancel visit, continuity of staff, etc.)
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Yes No Reviewed Client Rights and Responsibilities
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Yes No Reviewed Client Handbook
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Yes No Reviewed HIPAA and Client Privacy Rights including a review of Agency policies regarding HIPAA and Privacy Rights
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Yes No Obtained consent for services prior to providing care
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Yes No Obtained signatures on all required forms
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Yes No Advanced Directives and DNR status discussed and documented. DNR order obtained per Agency policy.
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OPENING AND ROUTINE VISIT |
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Yes No Scheduled visit by telephone the day before
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Yes No Introduces self to client at start of visit
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Yes No Explains purpose of visit, procedures before performing them
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Yes No Conducts a thorough organized physical, mental, and emotional assessment
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Yes No Checks and updates medical record with visit findings
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Yes No Care provided is congruent with physician orders and physician plan of care
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Yes No Client care instruction was at client/caregiver level of understanding
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Yes No Client/caregiver participated in the development of the Plan of Care
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Yes No The MD was notified of the assessment findings and the MD and RN collaborated on the development of the POC.
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INTERVENTIONS |
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Yes No Performed skilled care that was appropriate and specific to the client's health care needs
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Yes No Performed skilled care as ordered on the Plan of Care
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Yes No Skilled care performed per practice standards and in a safe correct manner
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Yes No Client/caregiver is included in decision (re: goals, treatment, schedule of next visit)
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Yes No RN asks appropriate questions
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Communication |
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Yes No RN greeted the client/caregiver courteously and appropriately
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Yes No RN explained actions prior to beginning interventions
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Yes No RN informed the client/caregiver of next scheduled visit and discussed expected activities or learning to be completed prior to the next visit and plan for next home visit
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Yes No RN notifies appropriate supervisor of change in visit frequency; for example, the need for a follow-up visit
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Yes No RN communicates any abnormal findings, problems, and/or concerns to the MD
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Yes No RN writes the physician order when received
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Yes No Notifies the RN Case Manager, RN Supervisor of any clinical problem and/or change in physician orders
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Yes No RN coordinated care with other disciplines and/or any other care providers as needed and documents communication and coordination.
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OTHER |
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Yes No RN reminds client/caregivers of their Rights & Responsibilities and of the ISDH phone # for the Complaint Hotline Number at every home visit
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Yes No Conducts visit in an organized, efficient manner
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Yes No RN maintains confidentiality of client information
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Yes No RN wears identification badge
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DOCUMENTATION |
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Yes No RN Completes all sections of nursing notes appropriately
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Yes No RN updates the medication profile with any new medications or changes in dosage or frequency
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Yes No RN revises the home health aide/attendant care assignment sheet when necessary, and notifies the Nursing Supervisor
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Yes No RN documentation reflects follow through on the Plan of Care
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Yes No The Clinical Record evidences congruency between the comprehensive assessments, the POC, the visit documentation
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