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Nurse Visit Form

Ameristar Home Healthcare, LLC utilizes a secure electronic medical charting system to document all patient visits. In the event that the electronic system is temporarily unavailable or inoperable, staff will obtain required patient signatures using this paper form.
By signing below, you acknowledge that a staff member from Ameristar Home Healthcare conducted a visit at your residence on the date and time indicated. If you do not agree with the date or time of the visit, please do not sign this form and contact our office immediately at (614) 489-7272 for clarification.
Thank you for your understanding and cooperation

Supervision

HHA Present?
Follows the patient care plan
Is the Patient/Client satisfied with the care/services?
Appears competent when providing services
Complies with infection prevention and control?
Reports client needs/conditions to supervisor in a timely manner?
Good personal grooming habits.?
Adheres to the dress code.?
Uses proper body mechanics.?
Honors patient's rights?
Clear Signature
MM slash DD slash YYYY
Time in
:
Time out
:
Clear Signature
MM slash DD slash YYYY
Clear Signature
MM slash DD slash YYYY

[email protected]

5668 Columbus Square
Columbus, OH 43231

(614) 489-7272

(614) 489-6871

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