SUPERVISORY VISITS FOR STAFF
I. CLIENT INFORMATION
Name of Client (Last, First, Middle)
*
Clinical Record No.
*
Staff person in Home During Supervisory Visit
*
Yes
No
Name of Staff Member being Supervised (Last, First, middle)
*
Signature of Nurse Supervisor Doing Supervisory Visit
*
Clear
Date of Supervisory Visit
*
/
Month
/
Day
Year
II. STAFF INFORMATION
Items
Staff Member
1. Reports for work assignments as scheduled.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
2. Identifies self by name and title to the client.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
3. Demonstrates courteous behavior towardthe client and others.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
4. Demonstrates cooperative behavior with theclient and others.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
5. Demonstrates positive and helpful attitudetoward the client and others.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
6. Demonstrates competent skills and expertise.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
7. Demonstrates adequate communication skills.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
8. Follows client care plan.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
9. Documents provided home health care servicesin an appropriate manner.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
10. Informs nurse supervisor of client needs andcondition as appropriate, in a timely manner.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
11. Adheres to home health care agency policies and procedures.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
12. Utilizes proper body mechanics.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
13. Utilizes good grooming habits.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
14. Complies with home health care agencydress code.
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
15. Other
Exceeds Requirements
Meets Requirements
Does Not Meets Requirements
NOTOBSERVED
Signature of Staff Member Being Supervised
*
Clear
Signature of Nurse
Clear
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