Appendix 8

Home Visiting Report Rubric

(5%)
Note: Submit one form at end of home visit month for all home visits

Activity Remarks

Activity implemented in each visit

1)In the first visit.

- Goal : Gather information about the The goal is met.
family, what they do, and find out their needs.
- Objective : 1)It has been agreed with
1.Give more accurate assessment of the the family to determine the
family structure . number and times of
2. Give assessment and evaluation of the upcoming visits and what
natural home environment and behavior health education topics they
in that environment . would like to know.
3.Time duration of each home visit shall not
exceed 20 minute To 1 hour.

2) The Second visit.

(goal) :
health education about the Imatinib
medication .
Nursing Interventions :
1. I discussed with the family and the client
about the side effects of the medication
and how to manage and what is the best
way to take the medication.
2. The family was presented with a brochure
about foods and nutritional supplements
that work to raise immunity and their
sources .
( The goal is met)
Agree with the family on the
date and duration of the
next visit. The subject of
the upcoming health
education was determined
based on the family's need
for childbirth dislocation
3)The third visit.
Goal:
Health education about childbirth dislocation
and re-evaluation of the previous visit.
Interventions :
1_The family was presented with a
detailed description of the symptoms and
causes of childbirth dislocation .
2_I gave them pictures of the forms of
devices that are being treated and how
to install them.
( The goal is met).
I agree with the family on
the date and duration of the
next visit. The next health
education topic has been
determined based on the
family's need.

Goal met
4)The Fourth visit.
Goal: Health education about hair and nail
care +termination with the family
Interventions:
1. We talked about the importance of
nutritional supplements that help us to
strengthen hair and nails, especially after
childbirth

2. We discussed the importance of a proper

diet that contains vitamins, calcium, iron, and
adequate amounts of protein for general health.
Evaluation of the activity and the achieved
objectives (SWOT) Strength, Weakness,
opportunities, threats.

Strength :

1- The family's enthusiasm and willingness to

acquire more information and knowledge.
2- 2- Calm, listen, and not distract the family during
the explanation.

Weakness: .
Deficiency in the material and economic aspect of the
family.

Opportunities :
The family's need for more information and health
education to improve and enhance their health.

Threats:

The family's need for more information and

health education to improve and enhance their
health

Page 28 of 34