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).
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Impairments/immobility
- Any indication of cognitive impairment?
- Employment/volunteering
- Reading
- Music
- Socialization
- Hobbies
- Other
- Ambulating
- Toileting
- Transferring
- Bathing
- Feeding
- Continence
- Dressing
- Balance - Static (Romberg test, standing reach test)
- Balance - Dynamic (walking, tandem walk)
- Gait - Left: arm swing, stance, leg swing, step
- Gait - Right: arm swing, stance, leg swing, step
Nutrition
- Eating habits
- Variety and quality of food
- Pantry
- Refrigerator
- Freezer
- Nutritional status
- Obesity
- Malnutrition
- Other
- Fluid intake
- Alcohol presence/use
- Swallowing difficulty
- Oral health
Home Environment
- Neighborhood
- Exterior of home
- Interior of home (select all that apply)
- Crowding
- Good housekeeping
- Hominess
- Privacy
- Pets
- Books
- Television
- Memorabilia
- Internet
- Information and communication technology
Other people
Medications
- Prescription drugs
- Nonprescription drugs
- Dietary supplements
- Medications organized
- Medication compliance
- Medication discrepancy
- Multiple prescribers
- Allergies to medications
- Written instructions
Examination
Safety
- Access to emergency services
Spiritual health
- Spiritual includes cultural and ethnic influences
Services
- e.g. fire, police, emergency medical services, home health, social services, meals on wheels, hospice, transportation, legal, equipment, health benefit advisor
Completion
- Comments/Recommendations
- Conducted by: Name & Signature Sign
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SafetyCulture Staff
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).
Print as PDF
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.
