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Home Visit Performance Evaluation Checklist

This document provides a performance evaluation checklist for home visits conducted by nursing students. It lists the key steps of the home visit process, including: 1) explaining the purpose of the visit, 2) inquiring about health and providing care, 3) demonstrating proper bag technique, 4) performing examinations and providing instruction. The student's performance on each step is rated on a scale of 1 to 5. The checklist is used to evaluate the student's preparation, procedures, and documentation during the home visit.

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Francis Gong
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696 views1 page

Home Visit Performance Evaluation Checklist

This document provides a performance evaluation checklist for home visits conducted by nursing students. It lists the key steps of the home visit process, including: 1) explaining the purpose of the visit, 2) inquiring about health and providing care, 3) demonstrating proper bag technique, 4) performing examinations and providing instruction. The student's performance on each step is rated on a scale of 1 to 5. The checklist is used to evaluate the student's preparation, procedures, and documentation during the home visit.

Uploaded by

Francis Gong
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

Ateneo de Zamboanga University

College of Nursing
PERFORMANCE EVALUATION CHECKLIST
HOME VISIT

NAME: _____________________________________ DATE PERFORMED: ______________________


YEAR & SECTION: ______________

Legend (Rating Criteria):


5 – Expert (student performs all tasks proficiently and independently).
4 – Competent (student performs efficiently in an effective and efficient manner).
3 – Progress Acceptable (performance is usually effective and but not always).
2 – Needs Improvement (progress in performance is too slow to judge satisfactorily; task performance is not
most of the time).
1 – Progress Unacceptable (no progress in performance has been demonstrated, and or performance is
consistently ineffective and inefficient).
Purpose of Home Visit:
 Initiate contact through home visit.
 Introduce self and the school
 Communicate interest in family welfare
 Maintain a two-way communication with the family
 Show willingness to help with expressed need/s.

PREPARATION
 Assemble the equipment PHN bag
PROCEDURE 1 2 3 4 5

1. Explain the purpose of home visit.


2. Inquire about health and welfare of client and other family members. Ask about
any health and health-related problems.
3. Place health bag in a convenient place using bag technique.
4. Wash hands, wear, apron (PRN) and take out needed articles from bag.
5. Perform physical examination.
 Administer nursing care. If more than one member has to be health
supervised/cared for, start with the well member to avoid transfer of
infection.
6. Give necessary health advice or teach basic health care based on client’s
needs and condition.
 If patient is weak or diagnosed with illness during a visit, give health
instructions to a responsible well member of the family.
 Make an appointment for next visit either at the health center or another
home visit.
7. Wash hands and close bag.
8. Record health status of family members and care administered.
TOTAL

__________________________
Clinical Instructor
(Sign over printed name)

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