Supervisory Visits of Home Health Care Staff
Patient Name
*
First Name
Last Name
MR #
*
Name of staff member being supervised
First Name
Last Name
Staff in home during Sup. Visit?
Yes
No
Signature of supervisor doing sup. visit
Date
-
Month
-
Day
Year
Staff Information
1: Reports for work assignments as scheduled
Exceeds
Meets
Does Not Meet
Not Observed
Comments
2: Identifies self (name and title) to patient
Exceeds
Meets
Does not Meet
Not observed
Comments
3. Demonstrates courteous behavior toward the patient
Exceeds
Meets
Does Not Meet
Not Observed
Comments
4. Demonstrates cooperative behavior with the patient and others
Exceeds
Meets
Does Not Meet
Not Observed
Comments
5. Demonstrates positive and helpful attitude toward the patient and others.
Exceeds
Meets
Does Not Meet
Not Observed
Comments
6. Demonstrates competent skills & expertise
Exceeds
Meets
Does Not Meets
Not Observed
Comments
7. Demonstrates adequate communication skills
Exceeds
Meets
Does Not Meet
Not Observed
Comments
8. Follows patient care-plan
Exceeds
Meets
Does Not Meet
Not Observed
Comments
9. Documents provided home health care services in an appropriate manner.
Exceeds
Meets
Does Not Meet
Not Observed
Comments
10. Informs supervisor of patient needs and conditions as appropriate in a timely manner.
Exceeds
Meets
Does Not Meet
Not Observed
Comments
11. Adheres to home health care agencypolicy and procedures.
Exceeds
Meets
Does Not Meet
Not Observed
Comments
12. Utilizes proper body mechanics
Exceeds
Meets
Does Not Meet
Not Observed
Comments
13. Utilizes good grooming habits.
Exceeds
Meets
Does Not Meet
Not Observed
Comments
14. Complies with home health care agency dress code.
Exceeds
Meets
Does Not Meet
Not Observed
Comments
15. Skilled interventions observed. (safe and effective)
Exceeds
Meets
Does Not Meet
Not Observed
Comments
16. Other: (specify)
Exceeds
Meets
Does Not Meet
Not Observed
Comments
Signature of Staff member being supervised:
Date
-
Month
-
Day
Year
Signature of Director:
Date
-
Month
-
Day
Year
SEND
Should be Empty: