ICF OBSERVATION ROUNDS
Person completing rounds:
*
First Name
Last Name
Email of person completing rounds:
*
example@example.com
Are you rounding on a weekday, or a weekend?
*
Weekday
Weekend
Which shift are you rounding on?
*
Day
Evening
Overnight
Please enter the names of the staff working during your rounds:
*
Location:
*
A1
A2
A3
B1
B2
B3
C2
C3
How many times did you visit the apartment?
*
1
2
3
4
5
Were checks and changes completed?
*
Yes
No
Check and change follow-up completed:
Was mobility/adaptive equipment clean (ex. wheelchairs, walkers, etc.)?
*
Yes
No
Mobility and adaptive equipment cleanliness follow-up completed:
Is documentation being completed?
*
Yes
No
Documentation follow-up completed:
Are meals being prepared according to menu?
*
Yes
No
N/A
Meal preparation follow-up completed:
Laundry level is:
Minimal
Excessive
Laundry follow-up completed:
Were there any privacy concerns identified?
Yes
No
Privacy concern follow-up completed:
Did the individual(s) have any updates or concerns?
*
Yes
No
Please describe any updates or concerns:
*
Update or concerns follow-up completed:
Are there any supplies needed?
*
Yes
No
Please list the supplies that are needed:
*
Supplies follow-up completed:
Additional notes/comments:
Submit
Should be Empty: