House Call Equipment Checklist

• Reference #

• Location
  Address

• Conducted by

• Conducted on

  Date

Physician-supplied

• The following are recommended:

• Bandage scissors

  Yes

  No

  N/A

• Cell phone

  Yes

  No

  N/A

• Cerumen spoons

  Yes

  No

  N/A

• Gauze/tape/packing

  Yes

  No

  N/A

• Gloves (sterile and nonsterile)

  Yes

  No

  N/A

• Glucometer

  Yes

  No

  N/A

• Lubricant

  Yes

  No

  N/A

• Maps or global positioning system (GPS)

  Yes

  No

  N/A

• Otoscope/ophthalmoscope

  Yes

  No

  N/A

• Phlebotomy equipment

  Yes

  No

  N/A

• Sharps container

  Yes

  No

  N/A

• Sphygmomanometer (variety of sizes)

  Yes

  No

  N/A

• Sterile specimen cups

  Yes

  No

  N/A

• Stethoscope

  Yes

  No

  N/A

• Tape measure

  Yes

  No

  N/A

• Thermometer

  Yes

  No

  N/A

• Tongue depressors

  Yes

  No

  N/A

• Tuning fork

  Yes

  No

  N/A

• The following are optional:

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

  Yes

  No

  N/A

• Dictaphone

  Yes

  No

  N/A

• Externally worn hearing amplifier

  Yes

  No

  N/A

• Personal digital assistant (PDA)

  Yes

  No

  N/A

• Portable electrocardiograph

  Yes

  No

  N/A

• Pulse oximeter

  Yes

  No

  N/A

• Vaccines (properly stored)

  Yes

  No

  N/A

Patient-supplied (as needed)

• Glucometer

  Yes

  No

  N/A

• Home blood pressure monitor

  Yes

  No

  N/A

• Nebulizer

  Yes

  No

  N/A

• Peak flow meter

  Yes

  No

  N/A

• Scale

  Yes

  No

  N/A

Documentation

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Billing documentation

  Yes

  No

  N/A

• Business cards/appointment cards

  Yes

  No

  N/A

• Patient record

  Yes

  No

  N/A

• Phonebook of essential community numbers and services

  Yes

  No

  N/A

• Prescription pad

  Yes

  No

  N/A

Completion

• Comments/Recommendations

• Conducted by: Name & Signature

  Sign