SAINT MARY’S UNIVERSITY

School of Health Sciences

Bayombong, Nueva Vizcaya

EVALUATION TOOL FOR HOME VISIT AND BAG TECHNIQUE

Name of Student: _______________________________________________Section:__________Group:________

DIRECTIONS: Below is a list of criteria to evaluate the student’s skill in conducting home
visit and performing bag technique. Indicate your evaluation by placing a check mark on
the appropriate column using the following descriptive scale.

STEPS 0 1 2 REMARKS
HOME VISIT AND BAG TECHNIQUE
1. Greet the patient and introduce self
2. State the purpose of the visit
3. Observe the patient and determines health needs
4. Put the bag in a convenient place then proceeds to
performing the bag technique
BAG TECHNIQUE
A. Upon arrival at the patient’s home, place the bag on
the table lined with a clean paper. The clean side must
be out and folded part, touching the table
B. Ask for a basin of water or a glass of drinking water if
tap water is not available
C. Open the bag and take out the towel and soap
D. Wash hands using soap and water. Wipe to dry
E. Take out the apron from the bag and put it on the right
side out.
F. Put out all necessary articles needed for the specific
care
G. Close the bag and put it in one corner of the working
area
H. Proceed in performing the necessary nursing care and
treatment
I. After giving the treatment, clean all things that were
used and perform hand washing
J. Open the bag and return all things that were used in
proper places after cleaning them
K. Remove apron, folding it away from the person, the
soiled side in and the clean side out. Place it in the bag
l. Take the record and have a talk with the mother. Write
down all necessary data that were gathered,
observations, nursing care and treatment rendered.
Give instructions for care of patients in the absence of
the nurse.
m. Make appointment for the next visit taking note of the
date and time
Total:______ Average:______
Comments:____________________________________________________________________________________________
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__________________________________________

Student’s signature over printed name/ Date/ Time: ____________________________________________

Clinical Instructor’s signature over printed name/ Date/ Time:

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