Telehealth Patient Assessment Checklist.

Purpose: To screen current patients of _____________ [the home health agency]
for appropriate admission to the telehealth program.

In-person assessment of patients is required to complete this checklist, and should be completed during a usual visit so that the nurse is able to judge the communication skills and other capabilities of the patient (and/or of a caregiver who, if the patient needs assistance, will be present at each telehealth interaction).

Name of Patient:

Name of Provider:

Branch Office:

Date:

Patient’s Capabilities

	Good	Adequate	Poor	Nonresponsive
Ability to See and Hear more then passably
Manual Dexterity
Understand Directions
Attitude Toward Technology
Ability to Tell Time
Understands the Patient Informed Consent Form

Patient’s Needs

	Yes	No
Requires two or more skilled nursing visits per week
Has history of repeat admissions
Has pain/symptom control issues
Specific disease management needs (renal dialysis, e.g.)
Special Needs (e.g., non-regular blood pressure cuff)

Notes:

Clinician Signature ______________________________ Date _____________

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