Pre-Visit Review and Preparation: On-Site Observations

Yes No NA Patient consents, Authorizations

Yes No NA Medication Profile Reviewed

Yes No NA Allergies noted on Med Profile

Yes No NA POC, Verbal Orders Reviewed

Yes No NA Copy of Patient Consents in Home Folder

Yes No NA Home Folder Confidentiality

Yes No NA Med. Profile in home reviewed for congruency

Yes No NA Allergies in home folder match clinical record

Yes No NA Clinical Documentation Reviewed

Yes No NA Appropriate Teaching Material in Home Folder

Yes No NA HHA/Attc Assignment Sheet Reviewed

Yes No NA HHA/Attc Assignment Sheet in Home Folder

Yes No NA Case Conferences/Care Coordination Present

Yes No NA Copy of Patient Rights, Consents, ISDH Hot Line Number in Home foldere


Yes No Hand washing with liquid/foam soap or substitute at appropriate times.

Yes No Cleans thermometer, stethoscope, and supplies between clients

Yes No Disposes of waste properly

Yes No NA Sharps container present

Yes No Nurse bag placed on clean, dry surface

Yes No Standard Precautions observed

Yes No NA Instructed client on storage and disposal of supplies

Yes No NA Supplies left in client's home were appropriately stored

Yes No Demonstrated safe appropriate use of equipment

Yes No Environmental safety assessed and appropriate instructions or referral given

Yes No Client safety evaluated (ambulates safely with assistive device/client safe in wheelchair)

Yes No NA Client’s DME equipment evaluated for signs of obvious malfunction (i.e., non-functioning brakes on a rolling walker)

Yes No NA Client oxygen safety evaluated


The Registered Nurse explained the following:

Yes No Home care services

Yes No Agency expectations

Yes No Reasonable client expectations (calling to cancel visit, continuity of staff, etc.)

Yes No Reviewed Client Rights and Responsibilities

Yes No Reviewed Client Handbook

Yes No Reviewed HIPAA and Client Privacy Rights including a review of Agency policies regarding HIPAA and Privacy Rights

Yes No Obtained consent for services prior to providing care

Yes No Obtained signatures on all required forms

Yes No Advanced Directives and DNR status discussed and documented. DNR order obtained per Agency policy.


Yes No Scheduled visit by telephone the day before

Yes No Introduces self to client at start of visit

Yes No Explains purpose of visit, procedures before performing them

Yes No Conducts a thorough organized physical, mental, and emotional assessment

Yes No Checks and updates medical record with visit findings

Yes No Care provided is congruent with physician orders and physician plan of care

Yes No Client care instruction was at client/caregiver level of understanding

Yes No Client/caregiver participated in the development of the Plan of Care

Yes No The MD was notified of the assessment findings and the MD and RN collaborated on the development of the POC.


Yes No Performed skilled care that was appropriate and specific to the client's health care needs

Yes No Performed skilled care as ordered on the Plan of Care

Yes No Skilled care performed per practice standards and in a safe correct manner

Yes No Client/caregiver is included in decision (re: goals, treatment, schedule of next visit)

Yes No RN asks appropriate questions


Yes No RN greeted the client/caregiver courteously and appropriately

Yes No RN explained actions prior to beginning interventions

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

Yes No RN notifies appropriate supervisor of change in visit frequency; for example, the need for a follow-up visit

Yes No RN communicates any abnormal findings, problems, and/or concerns to the MD

Yes No RN writes the physician order when received

Yes No Notifies the RN Case Manager, RN Supervisor of any clinical problem and/or change in physician orders

Yes No RN coordinated care with other disciplines and/or any other care providers as needed and documents communication and coordination.


Yes No RN reminds client/caregivers of their Rights & Responsibilities and of the ISDH phone # for the Complaint Hotline Number at every home visit

Yes No Conducts visit in an organized, efficient manner

Yes No RN maintains confidentiality of client information

Yes No RN wears identification badge


Yes No RN Completes all sections of nursing notes appropriately

Yes No RN updates the medication profile with any new medications or changes in dosage or frequency

Yes No RN revises the home health aide/attendant care assignment sheet when necessary, and notifies the Nursing Supervisor

Yes No RN documentation reflects follow through on the Plan of Care

Yes No The Clinical Record evidences congruency between the comprehensive assessments, the POC, the visit documentation