OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT
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Student Name: ___________________________________________ Score: _________________________

Level and Group No.: ______________________________________ Date: ________________________
Directions: Evaluate each step/task by putting (✔) under the proper heading. A numerical number may also be assigned &a minimum
passing level determined.
Rate the students from 2 - 0, where:
(2) Performed Correctly Students performed the step according to the standard procedure or guidelines
(1) Attempted Not Correctly Students unable to perform the steps/task according to procedure or guidelines
(0) Not Done Students did not do the step/task
(NO) Not Observed (NO) Evaluator unable to observe the step/task for various reasons like interruptions/inattentiveness,.

Checklist on Home Visit

STEP Performed Performed Not Not
Correctly but not Done Observed
(2) Correctly (0) (NO)
Done (1)

1. Greet the patient ,introduce yourself and state the

purpose of home visit
2. Observe the patient and determine the health needs.
3. Put the bag in a convenient place and then proceed to
perform the bag technique
4. Perform the nursing care needed and give health teachings.
5. Record all important data, observation and care rendered.
6. Make an appointment for a return visit.
Computation for student rating:
Raw score X 60 + 40
Perfect score

Student’s Signature and Date: _____________________________

Signature of Clinical Instructor and Date: ______________________

Remarks:
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