Home Health Random Visit/Monitoring Form
Location?
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Please Select
Phone
Home
Virtual/Web Meeting
1. Client Name
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2. Date
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Month
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Day
Year
Date
3. Have you experienced any of the following symptoms in the past 48 hours? Fever or chills Cough Shortness of breath or difficulty breathing Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea
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Please Select
Yes
No
4. If Yes whats the plan for care? Type N/A if the answer to number 3 was No.
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5. Is your caregiver present?
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Please Select
Yes
No
N/A
Select one.
6. Was your caregiver on time?
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Please Select
Yes
No
N/A
7. Any concerns
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8. Do you feel safe?
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9. Community/Building Elevators Working
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Please Select
Yes
No
N/A
10. Are all smoke detectors working in the home?
Please Select
Yes
No
11. Action plans to fix smoke detector/elevator issues
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Type N/A if not applicable.
12. Are any changes needed or notes?
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Is the staff asking for money, or food, telling you about their financial problems, or asking to borrow/loan them money food, or items? This is a safe space to share. Is there any uneasiness with debit cards, snap benefit cards, or other forms of payment? This is a safe space to share.
13. Admin Signature
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14. Date
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Month
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Day
Year
Date
Admin Name
First Name
Last Name
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