Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

Name: ________________________________ Rating: ________________________

Year and Section: _______________________ Group: ________ Date: __________

PROCEDURE CHECKLIST
HOME VISIT
Definition
A home visit is a professional face to face contact made by a
nurse/midwife to a patient or family to provide necessary health care
activities and to further attain an objective of agency.

Instruction: Below is the grading scale which will be used in rating your performance.
5 - Excellent - 95-100
4 - Very Satisfactory - 88-94
3 - Satisfactory - 82-87
2 - Fair - 76-81
1 - Needs Improvement - 70-75

STEP/TASK 5 4 3 2 1 REMARKS
Purposes:
1. To have a more accurate assessment of
the family’s living conditions and adapt
interventions accordingly
2. to educate the family about measures for
health promotion, disease prevention, and
control of health problems.
3. to prevent the spread of infection among
family members and within the community
4. to provide supplemental interventions for
the sick, disabled, or dependent family
member and, whenever possible, guide the
family on how to give care in the future.
5. to provide the family with greater access
to health resources in the community by
establishing a close relationship with them,
providing information and making referrals
as necessary.
PROCEDURE
I. PRE-VISIT PHASE
1. During the pre-visit phase, if
possible, contact the family and
determine their willingness for a
home visit.
2. Assess the willingness of the family
for a home visit. If family is willing,
appoint them for a home visit
schedule.
3. Formulate a plan for the home visit
 4. Before leaving the health facility,
check the contents of the nursing
bag and other articles.
5. Inform other members of the health
team (Barangay Captain or
Barangay Kagawad on Health,
Barangay Health Workers) of your
itinerary and as much as possible
apply the “buddy system” when
conducting home visits.
II. IN-HOME PHASE
A. INITIATION
1. Knock or ring the door bell and,
at the same time, in a reasonably
loud but nonthreatening voice
introduce and identify yourself as
the nurse in the community.
2. On entering the home,
acknowledge the family
member/s with a greeting and
introduce yourself and the
agency you represent.
3. At this point, observe the
environment for your own safety
4. Sit as the family directs you to
sit, or ask permission if you could
sit.
5. Establish rapport
6. State the purpose of the visit and
source of information
B. IMPLEMENTATION
1. Conduct interview and health
history taking
2. Perform the Bag Technique.
Observe aseptic practices.
Perform handwashing before and
after touching family members.
3. Conduct physical examinations,
and simple diagnostic
examinations if available for the
concerned family member.
4. Provide physical care, health
teachings and counseling to the
family as needed.
5. If further services cannot be
provided, explore with the family
other facilities for referral
6. Evaluate with the family what you
have accomplished during the
visit
C. TERMINATION
1. Summarize with the family the
events during the home visit
Set subsequent home visit or
another form of family-nurse contact
2. Record findings
 3. Thank the family extending their
time for a home visit
4. Return to the health facility
III. POST-VISIT PHASE
1. Document and record events that
transpired during the visit
2. If appropriate, a referral may be
made
3. If a subsequent visit has been
set, plan for the next visit.

Signed

WILMA N. BERALDE, MAN

Clinical Instructor