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Family Service Progress Record Template

This document contains a form for recording information about a family's living conditions, health, and progress receiving nursing services. Section I collects details about family members, their home environment, water source, kitchen, waste disposal, and community conditions. Section II documents identified health conditions and nursing problems. Section III outlines nursing care plans and objectives. Section IV is for recording service dates, observations, actions taken, and evaluations of progress. The form provides a way for nurses to comprehensively assess a family's needs and track the outcomes of interventions over time.

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Rodjhelyn Flor
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129 views4 pages

Family Service Progress Record Template

This document contains a form for recording information about a family's living conditions, health, and progress receiving nursing services. Section I collects details about family members, their home environment, water source, kitchen, waste disposal, and community conditions. Section II documents identified health conditions and nursing problems. Section III outlines nursing care plans and objectives. Section IV is for recording service dates, observations, actions taken, and evaluations of progress. The form provides a way for nurses to comprehensively assess a family's needs and track the outcomes of interventions over time.

Uploaded by

Rodjhelyn Flor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY: _____________________________________________________________________ FAMILY NUMBER: _________


ADDRESS: _______________________________________________________________________________________________________

I. Assessment of the Family, Home and Environmental Conditions:

A. 1. Members of the Household

FAMILY MEMBER RELATION SEX BIRTHDATE MARITAL HIGHEST EDUC. OCCUPATION REMARKS /
No NAME TO HEAD MONTH YEAR STATUS COMPLETED TYPE OF WORK PLACE DATE ENTERED

A. 2. Family Members not residing in the household but affect family resource generation and use

FAMILY MEMBER RELATION SEX BIRTHDATE MARITAL HIGHEST EDUC. OCCUPATION REMARKS /
No NAME TO HEAD MONTH YEAR STATUS COMPLETED TYPE OF WORK PLACE DATE ENTERED

A. Home and Environment


Date Assessed: ______________
1. Home
a. Ownership: ( ) owned ( ) rented ( ) rent-free
b. Construction materials used: ( ) light ( ) mixed ( ) strong
c. Number of rooms used for sleeping: ________________________
d. Lighting facilities: ( ) electricity ( ) kerosene ( ) others: specify
e. General Sanitary condition: _______________________________

2. Drinking Water Supply


a. Source: ( ) private ( ) public ( ) portability: ___________________
b. Distance from house: _______________________
c. Storage: ( ) none (direct from faucet or pipe) ( ) large covered container without faucet
( ) large uncovered container without faucet ( ) others, specify: _________________

3. Kitchen
a. Cooking facility: ( ) electric stove ( ) gas stove ( ) firewood/charcoal
b. Sanitary condition: ______________________________
c. Drainage facility: ( ) open drainages ( ) blind drainage ( ) none

4. Waste Disposal
a. Refuse and garbage
Container: ( ) covered ( ) open ( ) none
Method of disposal:
( ) hog feeding ( ) open burning
( ) open dumping ( ) garbage collection
( ) burial in pit ( ) others, specify: ___________________
( ) composting
b. Toilet
Type: ( ) none ( ) pail system
( ) overhung latrine ( ) antipolo type
( ) open pit privy ( ) water-sealed latrine
( ) closed pit privy ( ) flush type
( ) bored-hole latrine ( ) others, specify: ____________________
Distance from house: ________________________________
Sanitary condition: __________________________________

5. Domestic animals

KIND NUMBER WHERE KEPT


6. The Community in General
a. General sanitary condition: _________________________________________________
b. House congestion: ( ) Yes ( ) No
c. Presence of breeding sites of vector of diseases: ( ) Yes, specify: _________________ ( ) No
d. Recreational facilities: ________________________________________________
e. Availability of health care services (describe briefly): ______________________________________________________
f. Distance of house from nearest health care facility: _______________________________________________________

II. Health Condition and Problem Sheet

HEALTH CONDITIONS & NURSING PROBLEMS SUPPORTING DATA / DATE


PROBLEMS CUES IDENTIFIED RESOLVED

III. Nursing Care Plan

HEALTH CONDITIONS OR OBJECTIVES OF PLAN OF INTERVENTION EVALUATION PLAN


PROBLEMS AND FAMILY NURSING CARE OUTCOME CRITERIA / INDICATORS, METHODS / TOOLS
NURSING PROBLEMS STANDARDS
IV. Service and Progress Notes

DATE HEALTH CONDITIONS / NURSING NURSING OBSERVATIONS, ACTIONS TAKEN, RESPONSES & EVALUATION PRINTED NAME &
PROBLEMS OF PROGRESS / OUTCOMES SIGNATURE

Source:
Maglaya, A. S. (Ed). (2009). Nursing Practice in the Community. (5th ed.). Marikina City: Argonauta Corporation

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