Setting up your home for emergent situations

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Medications and med Hx

• Current med list

  Yes

  No

  N/A

• Are the medecines kept in the same place

  Yes

  No

  N/A

• Current list of medical history

  Yes

  No

  N/A

House acsessability (interior)

• Is main entrance acessable for a gurrney

  Yes

  No

  N/A

• Does House have secondary entry and egress point

  Yes

  No

  N/A

• Is secondary entry , gurnney acessable

  Yes

  No

  N/A

• Is the pt bed room acsessable for a gurrney

  Yes

  No

  N/A

• Are there stairs between the house entrance and the bed room

  Yes

  No

  N/A

• How far is the bed room from the mainentrance

  short

  medium

  long

• How acessable is the pt bed?

  very (bilateral)

  mostly (bilateral limited)

  seimi (one sided only)

  limited acsess

House acsessability (extierior)

• Is there a front gate to the yard

  Yes

  No

  N/A

• Yard type

  grass

  dirt

  gravel

• Is there a side walk from the street to the front door

  Yes

  No

  N/A

• Condition of side walk

  good

  satisfactory

  poor

• Is there a porch light

  Yes

  No

  N/A

• Does the porch light work

  Yes

  No

  N/A