Run Home Health Aide Supervisory Visit Documentation — Free

Visit Identification and Scope

Visit date and time recorded critical (required)

Patient and aide identifiers documented critical (required)

Record the patient name/ID and aide name/ID using agency-approved identifiers.

Supervisory visit interval met critical (required)

Confirm the RN supervisory visit occurred within the required agency/regulatory interval for aide supervision.

Yes No N/A

Visit type and setting confirmed

Reason for supervisory visit documented

Document routine supervision, follow-up on a concern, competency review, or other reason for the visit.

Aide Competency and Task Performance

Aide demonstrated correct completion of assigned tasks critical (required)

Assess whether the aide performed assigned duties according to the plan of care and agency standards.

Aide followed the plan of care and task limitations critical (required)

Yes No N/A

Aide communication with patient was appropriate and respectful

Aide required prompting or retraining

Note (optional)

Competency concerns identified critical (required)

Yes No N/A

Patient Care and Safety

Patient condition and response to care reviewed critical (required)

Document the patient's observed condition, tolerance of care, and any changes requiring follow-up.

Care delivered matched the care plan critical (required)

Yes No N/A

Safety hazards or non-conformances observed critical (required)

Yes No N/A

Patient environment was safe and accessible

Infection Control and PPE

Hand hygiene performed at appropriate times critical (required)

Yes No N/A

PPE used correctly for observed tasks critical (required)

Yes No N/A

Clean and dirty supplies were separated appropriately

Yes No N/A

Infection control deficiencies observed critical (required)

Yes No N/A

Documentation, Follow-Up, and Signature

Required documentation completed and legible critical (required)

Yes No N/A

Deficiencies and corrective actions documented

List any deficiencies, retraining provided, escalation, and follow-up due dates.

Follow-up plan established

Note (optional)

RN signature completed critical (required)

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Run: Home Health Aide Supervisory Visit Documentation

Visit Identification and Scope

Aide Competency and Task Performance

Patient Care and Safety

Infection Control and PPE

Documentation, Follow-Up, and Signature

Get your results