[Solution]Home Health Care Visit Checklist

Home Health Care Visit Checklist   Environmental Assessment Neighborhood:     Exterior of Home:   Interior of Home: (Check all that apply) Crowding Pets Good…

Home Health Care Visit Checklist
 

Environmental Assessment

Neighborhood:

 
 

Exterior of Home:

 

Interior of Home: (Check all that apply)

Crowding Pets
Good housekeeping
Books
Hominess Television
Privacy Memorabilia
 
Internet                              Information and Communication Technology
 
 

Safety:

(Check all that apply)
Access to Emergency Services
Alternative power source if needed
Adaptations to home needed
Telephone availability
 
 
 
Bathroom
Kitchen
Carpets
Lighting
 
 
 
 
Electrical cords
 
 
 
Fire/smoke detectors
Stairs
 
 
 
Fire extinguishers
Tables, chairs and other furniture
 
 
Emergency plans
Hot water heater
 
 
 
Evacuation routes
 
 
 
 
Gas or electric range
Heating/air conditioning
Water source
 
 

2. Medical/Surgical History

a. Medical History

 
 
 
 
 
 
b. Surgical History

 
 
 
 
 
 
3. Cognitive Status:

 
 
 
 
 
4. Sensory Assessment:

a. Hearing

 
 
 

b. Vision
 
 

 
 
 

c. Smell
 
 

 
 
 

d. Taste
 
 

 
 
 

e. Tactile
 
 

 
f. Falls
 
*Consult this Resource:
 
Fall Risk Assessment for Older Adults

 
 
 

 
5. ADL’s:
 
*Consult this Resource:
 
KATZ ADL Assessment

a. Ambulation
 
 

 
 
 

b. Toileting
 
 

 
 
 

c. Transferring
 
 

 
 
 

d. Bathing
 
 

 
 
 

e. Feeding
 
 

 
 
 

f. Continence
 
 

 
 
 

g. Dressing
 
 

 
6. IADL’s:
 
*Consult this Resource:
 
Lawton Instrumental Activities of Daily Living Scale

a. Employment/
 
 

Volunteering
 
 

 
 
 

b. Reading
 
 

 
 
 

c. Music
 
 

 
 
 

d. Socialization
 
 

 
 

Finances

 
 
 
 

Hobbies

 
 
 
 

Cooking/

food shopping
 
 
 

Housekeeping

 
 
 
 

Other

 
 
 
 

Nutrition: * Consult this Resource: Assessing Nutrition in Older Adults

Eating Habits

 

Variety and quality of food

 

c. Pantry

 
 
d. Refrigerator

 
 
e. Freezer

 
 
f. Nutritional status:

i. Fluid Intake

 
ii. Alcohol use

 
iii. Swallowing

Difficulty

 
iv. Oral health

 
v. Weight loss

 
vi. Obesity

 

 

 

 

 

 
 

 
 

8. Caregiver

 
 
 
 
9. Medications:

a. Prescription

 
 
 
 
 
 
b. Non-prescription

 
 
 
c. Dietary and Herbal

Supplements

 
d. Medication

compliance

 
e. Medication

discrepancy

 
 

f. Multiple prescribers
 
 

 
 
 

g. Allergies
 
 

 
 
 

h. Written Instructions
 
 

 
10. Vital Signs
 
 

a. Temperature
 
 

 
 
 

b. Pulse: Apical and
 
 

radial
 
 

 
 
 

c. Respirations
 
 

 
 
 

d. BP sitting and
 
 

standing
 
 

 
 
 

e. Weight
 
 

 
 
 

f. Pain
 
 

 
 
 
11. Mini-Mental State
 
 
 
*Consult this Resource:
 
 
 
Mental State Assessment of Older Adults: The Mini-Cog

 

 
 

12. General Physical

Condition:

 
 
 
 
 
 
 
 
 
 
13. Focused Examination:

 
 
14.  Spiritual Assessment: (Cultural and ethnic influence)
 

Community Services Needed: (Check all that apply)

Police
 
Home health
Fire
 
Social services
Emergency MOW
Medical services Hospice
 
Transportation
Legal
Equipment
 
 
Other:
 
16.  Enter the Name of the Additional Resource Tool Used
 

Enter results or assessment data from the tool

 
 
 

16. Narrative Note:
 

 
 
 
 
Name:                                                                                                                       
 
 
 
 
Date:                                                                                 

 
HomeCareChecklist3

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