1 home visit checklist for parent mentors initial ... - UT Southwestern

HOME VISIT CHECKLIST FOR PARENT MENTORS
INITIAL HOME VISIT
Start time: _________ Stop time: ___________ Total time to complete: _________
Parent Mentor Name: __________________________
Family ID/Last Name: ___________________________
Please circle where the family was recruited: CHW / Aurora
Date of Home Visit: ________________
Primary Care
Physician: ______________________
Physician Phone: ______________
Please circle whether the child was recruited in the ED or Inpatient wards: ED Visit / Hospitalization
1. COMPLETED BASIC ASTHMA EDUCATION
2. DISCUSSED THE DIFFERENCES BETWEEN DAILY AND RESCUE MEDICATIONS
Please complete the following tables with parents
Daily Medications
Name Dose Route (How Taken) When to take
Rescue Medications
Name Dose Route (How Taken) When to take
Does child have at least 2 MDIs with them at all times (one with the child and one at school) Yes No
If no, explain the importance of taking medication and encourage the child and parent to do so at all times
Does the child need refills for asthma medications now or within the next two weeks Yes No
If yes, explain ways to obtain a medication refill
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Does the child have any asthma medications that are expired, out, or almost out
Yes No
If yes, explain ways to obtain a medication refill
3. ASTHMA EQUIPTMENT
Are nebulizer machines, spacers, and peak flow meters all in working condition Yes No
If no, encourage families to contact their health care provider to obtain new equipment
4. HELP FAMILIES IDENTIFY EARLY AND LATE WARNING SIGNS OF AN ASTHMA ATTACK
Early Warning Signs
Late Warning Signs
5. ASTHMA CARE PLANS
Does child have a written asthma care plan from his/her health care provider (Please circle) Yes / No
If yes, does he/she follow his/her asthma care plan (Please circle) Yes / No
If yes, is there also a care plan for:
School Daycare Babysitters Other: __________________________
If no asthma care plan or if family doesn’t follow care plan, why / Additional Comments
Parent Mentor Review (place a check next to those discussed with parent; if something doesn’t
apply put “NA” in the box)
How to read/use asthma care plans
The importance of following asthma care plan
The importance of keeping asthma care plan at school/daycare/babysitters
Asthma care plan when child is showing early warning signs
Asthma care plan when child is showing late warning signs
Discussed daily asthma prevention
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6. PEAK FLOW METERS
Does child have a peak flow meter (Please circle) Yes / No
NA
If no explain to parents the importance of peak flow meters, instruct parent how to obtain
one (call health care provider
If yes, does the child use the peak flow meter when necessary (Please circle) Yes / No
NA
What is the child’s: Green zone: ________________
Yellow Zone: ________________
Red Zone:
________________
If no peak flow meter, family doesn’t regularly use peak flow meter, why
Additional Comments
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Parent Mentor Review (place a check next to those discussed with parent; if something doesn’t
apply put “NA” in the box)
When/how to use a peak flow meter
Peak flow chart
How to track peak flow results
How to clean peak flow meter
How to obtain new peak flow meter if lost or broken
Special recommendations from the child’s primary care provider
7. TRIGGERS
What are some things that make your child have an asthma attack (Check all that apply)
Tobacco Smoke
Mold
Strong Smells
Pets
Dust
Exercise
Foods
Cockroaches
Dust mites
Colds or Flu
Pollution
Grass
Flowers
Trees
Humidity
Cold or hot weather (temperature changes)
Ozone
Heat
Additional things that may make your child have an asthma attack
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Trigger/Environmental Control (Check all discussed with parent if not applicable put NA in box)
Damp dust surfaces weekly
Manage pests in the home
Avoid food allergens
Take steps to eliminate smoke in the home
Medications taken before and attainable during
exercise
Vacuum carpeted areas and furniture at least
once a week
Pillow Covers
Mattress covers
Establish “pet free zones”
Eliminate or wash heavy curtains
Eliminate stuffed furniture from the child’s
bedroom
Avoid strong smells (perfumes, scented lotion,
cleaning supplies, bleach)
Keep areas free of water and dampness
Get an annual flu shot
Wash bedding in hot water weekly
Change filters in air conditioners and humidifiers
Keep child away from trees and outdoor
triggers
Keep windows shut and use air conditioners
instead of fans
Stay inside during very hot/cold temperatures Keep child away from fresh flowers
Smokers in the home (Smoking Cessation)
8. ASTHMA AND SCHOOL/DAY CARE
Have parents:
Communicated asthma care plan with school/day care personnel Yes No
Notified school/daycare personnel about medications taken during school/day care hours Yes No
Given school/daycare emergency contact information Yes No
Medications given at school/daycare
Medication Name How much to take (dose) When to take
Triggers:
What are some things that make your child have an asthma attack at school/daycare (Check All that
apply
Stuffed Animals
Pillows
Dust on bookshelves and toys
Classroom pets
Plants or flowers
Chalk dust
Strong scents like
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Trigger/Environmental Control at school/daycare
(Check all discussed with parent if not applicable put NA in box)
Stuffed animals
Dust
Plants or flowers
Food
Change in weather
Pillows
Classroom pets
Chalk dust
Exercise
Strong scents
Parent Mentor Review (place a check next to those discussed with parent; if something doesn’t
apply put “NA” in the box)
Importance of having asthma care plan at school
Importance of notifying personnel about medications taken during school/daycare hours
Exercise-induced asthma
Comments
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
9. TRACKING REGULAR AND FOLLOW-UP APPOINTMENTS
Does the child have a primary health care provider Yes No
Does the child and family have regular scheduled visits for asthma Yes No
Has the child and family missed any of their child’s routine visits for asthma Yes No
If child and family have missed any appointments why/Comments
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Parent Mentor Review (place a check next to those discussed with parent; if something doesn’t apply put
“NA” in the box)
Importance of scheduled visits
Identify contact information for health care providers (give families contact resource sheet)
Identify next routine appointment with health care provider
Identify monthly meeting with other asthma families
10. CARE PLAN AFTER ED VISIT AND HOSPITALIZATION
Did family receive a care plan after ED visit or Hospitalization Yes No
Does the child have an asthma specialist Yes No
Date of the next follow-up appointment with health care provider: _____________________________
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