Client Homebound assessment
epitt
HomeCareChecklist3.docx
Home Health Care Visit Checklist
1. Environmental Assessment
a. Neighborhood:
b. Exterior of Home:
Home Health Care Visit Checklist
Page 1 of 11
c. Interior of Home: (Check all that apply)
Crowding Pets
Good housekeeping
Books
Hominess Television
Privacy Memorabilia
Internet Information and Communication Technology
d. 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
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2. Medical/Surgical History |
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a. Medical History |
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b. Surgical History |
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3. Cognitive Status: |
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4. Sensory Assessment: |
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a. Hearing |
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b. Vision |
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c. Smell |
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d. Taste |
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e. Tactile |
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f. Falls |
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5. ADL's: |
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a. Ambulation |
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b. Toileting |
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c. Transferring |
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d. Bathing |
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e. Feeding |
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f. Continence |
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g. Dressing |
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6. IADL's: |
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a. Employment/ |
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Volunteering |
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b. Reading |
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c. Music |
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d. Socialization |
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e. Finances
f. Hobbies
g. Cooking/
food shopping
h. Housekeeping
i. Other
7. Nutrition: * Consult this Resource: Assessing Nutrition in Older Adults
a. Eating Habits
b. 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
Home Health Care Visit Checklist
Page 6 of 11
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8. Caregiver |
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9. Medications: |
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a. Prescription |
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b. Non-prescription |
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c. Dietary and Herbal |
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Supplements |
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d. Medication |
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compliance |
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e. Medication |
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discrepancy |
Home Health Care Visit Checklist
Page 7 of 11
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f. Multiple prescribers |
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g. Allergies |
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h. Written Instructions |
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10. Vital Signs |
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a. Temperature |
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b. Pulse: Apical and |
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radial |
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c. Respirations |
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d. BP sitting and |
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standing |
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e. Weight |
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f. Pain |
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11. Mini-Mental State |
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12. General Physical |
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Condition: |
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13. Focused Examination: |
14. Spiritual Assessment: (Cultural and ethnic influence)
Home Health Care Visit Checklist
Page 10 of 11
15. 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
a. Enter results or assessment data from the tool
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16. Narrative Note: |
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Name: |
Date: |
