UWNI Home Health Monthly IP Visit

• Site conducted

  Select

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Sheet1

• HH Staff Member:

Bag Techniques and Equioment Management:

• Adequate patient care work space was maintaned: clean, kept away from traffic, pets, children, heat or cooling vents, with adequate lighting

  Yes

  No

  N/A

• Clinical bag was placed in liner or hung to keep off floor and upholstered furniture

  Yes

  No

  N/A

• Hand Hygiene was performed prior to entering/reentering clinical bag

  Yes

  No

  N/A

• Equipment &/or clean items removed from clinical bag were placed on a clean surface such as a liner or paper towel

  Yes

  No

  N/A

• Clinical bag was kept closed when not in use

  Yes

  No

  N/A

• Clinical bag items were disinfected and allowed to dry prior to placing back into bag

  Yes

  No

  N/A

• Laptop computer was disinfected with manufacturer approved wipe and allowed to dry, prior to placing into storage

  Yes

  No

  N/A

• Hand hygiene was performed between patient care and touching keyboard/device

  Yes

  No

  N/A

• Laptop computer/device was stored away from patient care supplies

  Yes

  No

  N/A

• Cell phone was disinfected with manufacturer approved wipe and allowed to dry prior to placing into bag or on person prior to leaving home

  Yes

  No

  N/A

• Reusable equipment removed from the home, placed in a separate bag, labeled and transported to agency decontamination area (bloody drainage is placed in biohazard bag)

  Yes

  No

  N/A

Hand Hygiene Competency:

• At the beginning of the home visit

  Yes

  No

  N/A

• At the end of the home visit

  Yes

  No

  N/A

• Prior to entering/reentering the clinical bag

  Yes

  No

  N/A

• Prior to touching patient's intact skin

  Yes

  No

  N/A

• After touching patient's intact skin

  Yes

  No

  N/A

• Before donning gloves

  Yes

  No

  N/A

• After removing gloves

  Yes

  No

  N/A

• Before preparing medications

  Yes

  No

  N/A

• Before performing a procedure

  Yes

  No

  N/A

• After performing a procedure

  Yes

  No

  N/A

• Before moving from a contaminated body site to a clean body site

  Yes

  No

  N/A

• Hand hygine supplies readily available

  Yes

  No

  N/A

• Opportunity Count

PPE usage:

• Appropriate PPE utilized during visit

  Yes

  No

  N/A

Biohazard Material Management

• Maintained appropriate biohazard disposal procedures

  Yes

  No

  N/A