Home visit checklist
Home visit checklists are used by healthcare professionals when conducting house calls to assess the medical condition of patients and provide patient care. this digital home visit checklist covers the patient’s immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, and other services needed (inhomesss).
What does this form include?
This form contains 40 sections:
Impairments/immobility
- Any indication of cognitive impairment?
Advanced activities of daily living (select all that apply)
Activities of daily living (select all that apply)
Any issues with balance and gait (select all that apply)
Eating habits
Variety and quality of food
Nutrition
Freezer
Nutritional status
Obesity
Malnutrition
Other
Fluid intake
Alcohol presence/use
Swallowing difficulty
Oral health
Neighborhood
Exterior of home
Interior of home (select all that apply)
Other people
Prescription drugs
Nonprescription drugs
Dietary supplements
Medications organized
Medication compliance
Medication discrepancy
Multiple prescribers
Allergies to medications
Written instructions
Weight
Examination
Examination
Examination
Examination
- General physical condition
- Depression screening
Focused examination
Safety
- Access to emergency services
- Alternative power source if needed
- Adaptations to home needed
- Telephone availability
- Bathroom
- Kitchen
- Carpets
- Lighting
- Electrical cords
- Stairs
- Tables, chairs, and other furniture
- Hot water heater
- Fire and smoke detectors
- Fire extinguishers
- Emergency plans
- Evacuation route
- Gas or electric range
- Heating/air-conditioning
- Water source
Spiritual includes cultural and ethnic influences
e.g. fire, police, emergency medical services, home health, social services, meals on wheels, hospice, transportation, legal, equipment, health benefit advisor
Comments/Recommendations
Conducted by: Name & Signature
Use this template