Supervisory Form

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
Should be Empty: