Home visit report for ‘Challenging CF’ protocol
Name: Address:
Dob:
Hospital no:
Date of visit: Telephone no:
Name of Nurse performing visit:
Name of Physiotherapist performing visit:
Those at home at time of visit:
The Home: Flat/House/Garden
If flat: what floor? Lift: yes / no Stairs: yes / no
Immediate surroundings (i.e. busy road, trees, fields):
No of bedrooms:
Shared bedroom: yes/no
People living at home: 1. 4.
2. 5.
3. 6.
Pets:
Pets in the home:1. Pets living outside:1.
2. 2.
3. 3.
Other information ______
Overall impression of home organisation:
Very organised Average Below average Very disorganised
Comments:______
Allergen Exposure
Moulds
Evidence of damp yes / no details:
Evidence of mould on walls yes / no details:
Evidence of mould on windows yes / no details:
Other allergens/irritants:
i.e. air fresheners, poor ventilation, mouldy food, rodent infestations etc
______
Smoke
Does Child smoke? yes/no
Do Parents smoke yes / no If yes; inside / outside
Other household members? yes / no
Do close friends smoke? yes/no
Evidence of smoke in home yes / no details:
Evidence of active smoking yes / no
Any known Allergies? yes / no Details:
Action required?
Medication
Current medication:
Antibiotics / Name / Dose / Frequency / Route / Available / In dateYes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Antifungal / Yes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Vitamins / Yes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Anti-reflux / Yes / no / Yes / no
Other / Yes / no / Yes / no
Current Inhaled /nebulised Medication:
Name / Dose/Frequency / Route / Available / In dateYes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Yes / no / Yes / no
Nebuliser make:
Date of last nebuliser service:
Cleanliness of machine:
Correct cleaning/sterilization technique yes/no
Correct administration of nebulised medication yes/no
I-neb use: yes/no if yes assess computer data: result
Inhaler technique reviewed: yes/no comment:
Other medication previously used:
Medication location:
Spares available: yes / no / some
Appropriate devices: yes / no / some details:
Do parents supervise yes / no / sometimes
Inappropriate amount of un-used med (stockpiling) yes / no comment:
Prescription pick up rate: <50% / 50 -80% / >80%
Details of medications issues discussed:
(ie understanding of medication regime, knowledge of drug types, management of exacerbations etc)
Advice given: ______
Physiotherapy.
Airway clearance technique:
ACBT ¨ Positioning ¨ Manual Techniques ¨ AD¨ PEP MASK ¨ Pari PEP ¨ Flutter
¨ Acapella ¨ None ¨ Other ¨ Please specify…
Frequency :
Duration:
Other techniques tried:
Exercise:
Posture Assessment:
Assessment of stress urinary incontinence:
Other comments:
Nutritional Issues
Enzyme replacement therapy yes/no
Type: Dose:
Daily Routine of use (including at school):
Gastrostomy: yes/no
Feeding regimen:
Psychosocial issues
Previously identified issues yes / no
If yes give details: ______
Appropriate perception of CF severity: yes / no
If yes give details: ______
Psychosocial issues discussed at home visit:
(continue on separate page if necessary) ______
Referral to psychology made: yes / no
Plan:
1.
2.
3.
4.
Summary of home visit: Signed:
2