Name: _______________________________________ Yr & Sec: _________ Date : ___________ Score: __________

HOME VISIT & BAG TECHNIQUE CHECKLIST

Steps/Procedures Correctly Done Incorrectly Not Done

Done
1. Greet client or household member and introduce yourself
2. Explain purpose of home visit
3. Inquire about health and welfare of client/patient and other family
members. Ask about health and health related problems.
4. Ask for a basin of water and a glass of water if faucet is not
available.
Place this outside work area
5. Open the bag, take out plastic lining and spread over work field
area. The paper lining, clean side out (folded part out). Spread plastic
lining over paper lining. This will be your work area.
6. Take out small cloth bag with its contents
(hand towel, soap dish) and apron and place them at one corner of the
work area (within the confines of the linen/plastic lining
7. Take off wrist watch and place on top of the table or the floor
outside of the work area, and convenient for you to glance on
8. Do hand washing with soap and water, using pouring method. Use
hand brush if necessary. Wipe dry with towel, fold back hand towel
and put it back in its place in the work area. leave the plastic wrappers
of the towel in soap dish in the bag.
9. Put on apron right side out and wrong side with crease touching the
body, sliding the head into neck strap. Neatly tie straps at the back
10. Put out things most needed of specific case (e.g. thermometer,
kidney basin, cotton ball, waste paper bag) and place at one corner of
the work area
11. Place paper bag (waste receptacle) outside of work area
12. Close the bag
. Performs physical assessment and nursing care needed.
13. Proceed with the specific nursing care or treatment
14. After completing the nursing care or treatment, clean and disinfect
the things used. For dirty and soiled instruments wash separately with
soap and water. Wipe them dry.
15. Do hand washing again
16. Open the bag and put back all articles in their proper places
17. Remove apron folding away from the body with soiled side folded
inwards and clean side out. Place in the bag.
18. Fold plastic lining (top side, folded in), then fold paper lining
(bottom side in) and return then back to the bag (over the inner cover
of the bag) and lock the bag.
19. Write down all necessary data that were observed, nursing care
and treatment rendered. Give instructions for care of patients in the
absence of a nurse
20. Give necessary health teaching and advice based on client's
patient’s needs and condition
21. Make post visit conference on matters relevant to health care,
taking anecdotal notes preparatory to final reporting
22. Make appointments for the next visit (either home or clinic) taking
note of the date, time and purpose
23. Documentation

SCORE: _____________

Arrangement of the bag:

1. Front
2. Back
3. Right side
4. Left side
5. Center
6. Top
7. Cover pocket