HOME HEALTH AIDE SUPERVISORY VISIT RECORD

HOME HEALTH AIDE SUPERVISORY VISIT
Sunrise Family Healthcare - 132 N. Wilson Rd Col, Ohio 43204

When clients are receiving skilled nursing services in addition to personal care, the Registered Nurse will make a supervisory Visit to the client's residence at least every Two (2) Weeks. If only therapy services are being provided in addition to personal care, the supervisor visit may be done by the Therapist in place of the Registered Nurse.

If clients are receiving Only home health aides services and there is no skilled services provided, a registered nurse will make a supervisory visit while the aide is providing care at least once every SIXTY (60DAYS) or Per State / Agency guidelines.

Patient Name : *

Record # : *

Aide(s) being Supervised: *

Date of Supervision : *

PERFORMANCE

The aide(s) follows and implements the care plan *

Yes

The aide(s) maintains and implements Universal Precaution per agency policy *

Yes

The aide(s)performs tasks as required by the client without job description *

Yes

The aide(s)is prompt, stays required length of time and is reliable *

Yes

The aide(s)adheres to the dress code *

Yes

The aide(s)relates well with the patient/family *

Yes

The aide(s) is caring and sympathetic to the client’s needs *

Yes

The aide(s)reports complications and problems to case manager/supervisor *

Yes

Does the client have a continued need for aide services? *

Yes

Home Health Aide Supervision

Is the agency admitting folder readily available? *

Yes

Has the home health aide care plan been updated as required? *

Yes

Aide Present? (Supvisits can be done either way) *

Yes

Additional Instructions given/Comments

Consumer is Satisfied with the Home Health aide services. Agency will continue with the care plan.

Consumer is NOT satisfied. Changes will be made to aide care plan and follow-up is needed.

Verified by:
(Auto-Populate Nurse name from Employee List"

[ Patient Signature on file]

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