Home Care Client Visit Form

Status

First CheckSecond CheckThird CheckOther

Client’s Name

Address

Type Full Address

Field Worker/Social Worker Name

Field worker / Social Worker Email*

example@emerest.com

Date of Visit*

Date

Name and relationship of person interviewed if other than client

Employee's Weekly Shift

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Hours

1. Pre-Visit Preparation: Care Plan Review

Reviewed client's care plan and medical history.All necessary documents and forms are on hand.Verified appointment details and address.

Comments

2.Introduction and Communication

Greeted the client/caregiver respectfully.Introduced yourself and explained your role.Explained the purpose of the visit.

Comments

3.Assessment of Client's Well-Being

Observed overall demeanor and appearance.Assessed changes in health since the last visit.Discussed client's feelings and emotional well-being.

Comments

4.Nutritional Assessment

Discussed dietary preferences and restrictions.Checked eating habits and nutritional intake.Assessed hydration levels.

Comments

5.Personal Care and Hygiene

Ensured the client is maintaining personal hygiene.Discussed challenges or assistance needed.Addressed any skin issues or concerns.

Comments

6.Mobility and Safety

Confirmed the use of mobility aids.Discussed changes in mobility and comfort.Assessed home environment for safety hazards.

Comments

7. Residence Condition Assessment

Evaluated cleanliness and organization of the home.Identified safety hazards or maintenance needs.Discussed client's comfort and satisfaction with living conditions.

Comments

8. Communication and Client Preferences:

Discussed concerns or issues with the client.Encouraged open communication about needs and prefrencesUpdated the client on relevant information or changes.

Comments

9. Social and Emotional Support:

Assessed social connections and support network.Discussed social activities or community involvement.Provided emotional support and addressed loneliness

Comments

10.Review and Update Care Plan:

Reviewed current care plan with client and caregiver.Discussed adjustments or additional support needed.Updated care plan based on the assessment.

Comments

11.Collaboration with Caregivers

Communicated with the caregiver about client's status.Addressed caregiver concerns or questions.Provided guidance on caregiving tasks if necessary.

Comments

12.Caregiver Competency and Satisfaction:

Assessed caregiver's competency in providing care.Discussed caregiver's satisfaction with the caregiving roleAddressed any concerns or challenges the caregiver may be facing

Comments

13.Supervisory Visits of Home Care Staff:

Conducted supervisory visit with home care staff.Discussed caregiver performance and adherence to care planProvided feedback and addressed any training needs.

Comments

14.Emergency Preparedness:

Confirmed emergency contact information.Ensured client and caregiver are aware of emergencyVerified location of emergency supplies.

Comments

15.Documentation and Reporting:

Documented observations, assessments, and discussions.Reported changes or concerns to the supervisor.Ensured accurate and timely record-keeping.

Comments

16.Closure and Next Steps:

Summarized key points discussed during the visit.Confirmed date and time of next visitProvided contact information for follow-up questions or concerns.

Comments

Client Quality Assurance Questions

	YES	NO
1. Is your home care provider punctual
2. Does she/he arrive on each scheduled day?
3. Does she/he ever leave early?
4. Are you satisfied with the quality of care provided?
5. Is your home care provider a good companion
6. Do you have the same home care provider each day?

Comments and Overall Review:

Summarize your visit findings

Signature of Client

Signature of Home Care Employee (Social Worker/Nurse/Coordinator)

Did you check for Employee's ID?

Yes, checked Employee’s ID

Comments on Caregiver:

Short overall comment regarding your observations of the caregiver

Home Care Client Visit Form

Checklist