Ateneo de Zamboanga University
College of Nursing
PERFORMANCE EVALUATION CHECKLIST
HOME VISIT
NAME: ___________________ DATE PERFORMED: ______________________
YEAR & SECTION: ______________
Description:
A nursing home visit is a family-nurse contact which allows the health worker to assess the home and family sit-
uations in order to provide the necessary nursing care and health related activities. In performing home visits, it
is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired out-
comes.
Rationale:
Comprehensive Assessment: Enables healthcare or social workers to observe the patient’s living
environment, which provides context to their health status, lifestyle, and challenges that may not be
apparent in a clinical setting.
Personalized Care: Facilitates tailored interventions based on the actual conditions and resources
available at home, improving the relevance and effectiveness of care plans.
Early Identification of Risks: Helps detect potential safety hazards, hygiene issues, or social factors
(like family dynamics, support systems, or isolation) that could affect the patient’s health and well-being.
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.
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).
PREPARATION
Safe and Quality Nursing Care, Management of Resources and Environment
Assemble the equipment PHN bag
Rationale:
This is essential for delivering effective and timely care while minimizing the risk of infection and transmission
PROCEDURE 1 2 3 4 5
Communication, Health Education, Ethico-Moral Responsibility
Explain the purpose of home visit.
1. Rationale:
Informs the client about the procedure, alleviates anxiety, and promotes
understanding.
Ethico-Moral Responsibility, Safe and Quality Nursing Care
2. Inquire about health and welfare of client and other family members. Ask about
any health and health-related problems.
Rationale:
Maintains dignity and confidentiality, fostering trust and comfort
Safe and Quality Nursing Care, Management of Resources and Environment
3. Place health bag in a convenient place using bag technique.
Rationale:
To prevent contamination and ensure efficient, safe nursing care.
Safe and Quality Nursing Care
4. Wash hands, wear, apron (PRN) and take out needed articles from bag.
Rationale:
Prevents infection and maintains a sterile environment.
Safe and Quality Nursing Care, Research
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.
Rationale:
To objectively assess the patient's current health status through direct observa-
tion and structured evaluation, identifying any signs or symptoms that may not
have been reported or noticed otherwise.
Communication, Health Education, Ethico-Moral Responsibility
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.
Rationale:
Providing education in the home setting allows the nurse to demonstrate proce-
dures and health practices directly, ensuring better understanding and compli-
ance.
Safe and Quality Nursing Care
Wash hands and close bag.
7.
Rationale:
Prevents infection and maintains a sterile environment.
Records Management, Quality Improvement
8. Record health status of family members and care administered.
Rationale:
Ensures legal documentation and allows for continuous quality monitoring of
care.
TOTAL
__________________________
Clinical Instructor
(Sign over printed name)
Prepared by: Divince O Ekstrom, RN MAN
Description
A nursing home visit is a family-nurse contact which allows the health worker to assess the home and
family situations in order to provide the necessary nursing care and health related activities. In perform-
ing home visits, it is essential to prepare a plan of visit to meet the needs of the client and achieve the
best results of desired outcomes.
Purposes
1. To give care to the sick, to a postpartum mother and her newborn with the view teach a re-
sponsible family member to give the subsequent care.
2. To assess the living condition of the patient and his family and their health practices in order
to provide the appropriate health teaching.
3. To give health teachings regarding the prevention and control of diseases.
4. To establish close relationship between the health agencies and the public for the promotion
of health.
5. To make use of the inter-referral system and to promote the utilization of community services
Principles
The following principles are involved when performing a home visit:
1. A home visit must have a purpose or objective.
2. Planning for a home visit should make use of all available information about the patient and
his family through family records.
3. In planning for a home visit, we should consider and give priority to the essential needs if the
individual and his family.
4. Planning and delivery of care should involve the individual and family.
5. The plan should be flexible.
Guidelines
The following guidelines are to be considered regarding the frequency of home visits:
1. The physical needs psychological needs and educational needs of the individual and family.
2. The acceptance of the family for the services to be rendered, their interest and the willingness
to cooperate.
3. The policy of a specific agency and the emphasis given towards their health programs.
4. Take into account other health agencies and the number of health personnel already involved
in the care of a specific family.
5. Careful evaluation of past services given to the family and how the family avails of the nurs-
ing services.
6. The ability of the patient and his family to recognize their own needs, their knowledge of
available resources and their ability to make use of their resources for their benefits.
Steps
1. Greet the patient and introduce yourself.
2. State the purpose of the visit
3. Observe the patient and determine the health needs.
4. Put the bag in a convenient place and then proceed to perform the bag technique.
5. Perform the nursing care needed and give health teachings.
6. Record all important date, observation and care rendered.
7. Make appointment for a return visit.
Reference: https://nurseslabs.com/nursing-home-visit/
