Title Page

  • Reference #

  • Location
  • Conducted by

  • Conducted on

Equipment and Documents

Physician-supplied

  • The following are recommended:

  • Bandage scissors

  • Cell phone

  • Cerumen spoons

  • Gauze/tape/packing

  • Gloves (sterile and nonsterile)

  • Glucometer

  • Lubricant

  • Maps or global positioning system (GPS)

  • Otoscope/ophthalmoscope

  • Phlebotomy equipment

  • Sharps container

  • Sphygmomanometer (variety of sizes)

  • Sterile specimen cups

  • Stethoscope

  • Tape measure

  • Thermometer

  • Tongue depressors

  • Tuning fork

  • The following are optional:

  • Computer (portable printer and fax, wireless card, electronic health record)

  • Dictaphone

  • Externally worn hearing amplifier

  • Personal digital assistant (PDA)

  • Portable electrocardiograph

  • Pulse oximeter

  • Vaccines (properly stored)

Patient-supplied (as needed)

  • Glucometer

  • Home blood pressure monitor

  • Nebulizer

  • Peak flow meter

  • Scale

Documentation

  • “Advance packet” (names, phone numbers, policies, scope of services, questionnaires and patient forms)

  • Assessment tools (e.g., Mini-Mental State Examination, Geriatric Depression Scale, Screen for Caregiver Burden)

  • Billing documentation

  • Business cards/appointment cards

  • Patient record

  • Phonebook of essential community numbers and services

  • Prescription pad

Completion

  • Comments/Recommendations

  • Conducted by: Name & Signature

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