Nursing Home Visitation Checklist for Caregivers
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- Georgina Bell
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1 Nursing Home Visitation Checklist for Caregivers Caregivers are often responsible for monitoring their loved ones health, safety and well-being. Knowing how to properly check on a nursing home patient throughout his or her residency will help you prevent neglect or abuse by addressing issues before they become serious problems. To properly monitor your loved one s health, safety and well-being over time, we recommend that you complete a copy of this checklist during or after each visit. Save every completed form in a binder or folder. This will allow you to quickly and easily track changes over time. A visit with your loved one should be a special time. We hope this tool allows you to spend more quality time together. Visit Summary Schedule a free case review: Date of Visit:, 20 Time of Visit: : AM PM Time Elapsed Since Last Visit: Days Weeks Months Were all follow-up items of concern from last visit addressed? Yes No N/A Outcome/Additional Items for Follow Up: For Next Visit: Follow Up Items or Things to Bring Item Person to Follow Up With About/Thing to Bring
2 Mood & Appearance Observations about Patient Condition Rate the following attributes based upon your observations of the patient: Worst Best Level of Happiness: Level of Socializing: Level of Grooming/Hygiene: Significant Changes from last visit: General Health Rate the following conditions based on your observations of the patient and your understanding of their condition: No Discomfort Highest Discomfort Level of Pain and Discomfort: Level of Sleeping Trouble: Level of Fatigue: Level of Nausea/Constipation: Significant Changes:
3 Observations about Patient Condition (continued) Any pronounced weight loss or gain? Any bed sores or pressure sores?* Any evidence of depression, anxiety or other mood changes? Any evidence of bruises, cuts, marks, sprains, broken bones or other physical changes?* Any other evidence of mental, physical, emotional or sexual abuse?* Any other observations or changes in patient s health? *If you answered Yes to any question with an asterisk, call us immediately: Condition of the Facility Rate the following facility conditions on cleanliness and maintenance by checking the appropriate boxes and adding comments. Floors Guardrails Wheelchairs Bed Bathrooms Cafeteria Activity rooms Smell of facility Great Adequate Unacceptable Material changes from last visit:
4 Interactions with Staff Notable conversations with staff on this visit Person(s) spoke with: Position(s): Nature of Conversation(s): Were requests to see the patient delayed or refused? Are there any changes in nursing home staff? Are there any changes in nursing home staff morale or attitude? Any change in relationship between patient and staff? Any other noteworthy observations or changes regarding staff?
5 Patient Care Changes to Medication or Treatment Plan Medication/Treatment Dose/Duration Time of Distribution Changes to Meals/Feeding Type of food Amount Time of Day Changes to Activity Type of Activity Duration Day & Time Changes in Nursing Home Policies? The Nursing Home Abuse Attorneys at Furnari Scher are dedicated to helping families prevent and end nursing home abuse. If you ever require our assistance or more information, please do not hesitate to call us. We will review your situation for free, and you are under no obligation to hire us. If legal action is required, we shoulder the entire burden of building and pursuing your case, and there is no fee unless the case is resolved favorably. Learn more at or call us at
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