In-Home Site Visit Report

Location *

Patient Type

What Type of Site Visit Is This Request For? *

Patient First Name *

Patient Last Name *

Site Visit Date

Site Visit Time

Aide First Name

Aide Last Name

Nurse First Name

Nurse Last Name

Patient CLTC No.

Personal Care Level of Service (e.g. companion care, personal care, respite care)

Personal Care Total Hours

Aide or Supervisor First Name

Aide or Supervisor Last Name

Aide Status *

Introduction of New Staff or Routine Checking on Current Staff *

Any Observation That Need to Be Noted

Personal Care Needs of Patient Met *

Plan of Care Reviewed/Revised *

Care Plan Comments

Is the Client/Family Satisfied with Services? *

Satisfaction Comments

Environment Noted with No Safety Issues *

Environment Comments

1) Aide Has Necessary PPE & Name Badge *

PPE/Badge Comments

2) Review of Aide Timesheet/Service Log *

Timesheet Comments

3) Aide Uses Hand Washing/Hand Hygiene *

Hand Hygiene Comments

4) Demonstrates Compliance with Standard Precautions *

Standard Precautions Comments

5) Performs Tasks/Hours of Service as Specified on Plan of Care *

Comments/Areas to Improve

6) Questions/Concerns by Patient, Aide, and/or Other or Custom Care Plans *

7) Response *

8) Time In *

Time Out *

Supervisor Site Visit — Full Name *

Supervisor Title (e.g. RN)

Date *

Supervisor Signature — type your full legal name to sign *