HOME HEALTH ASSESSMENT &
MONITORING CHECKLIST
A structured checklist for evaluating vitals, wound care, respiratory status, medication adherence, safety risks, and caregiver capacity in the home setting.
Home‑health clinicians must perform thorough assessments, monitor for changes in condition, educate caregivers, and escalate concerns promptly. Because visits are intermittent, every assessment must be complete, accurate, and well‑documented.
This checklist helps attorneys evaluate whether home‑health staff met clinical expectations, responded appropriately to changes, and communicated effectively with physicians and caregivers.
Use this tool during breach analysis, deposition preparation, and timeline reconstruction.
ADMISSION ASSESSMENT REQUIREMENTS
✔ Comprehensive Assessment Must Include
• Vital signs
• Pain assessment
• Respiratory status
• Cardiovascular status
• Neurological status
• Skin integrity
• Wound assessment (if applicable)
• Hydration and nutrition
• Mobility and fall risk
• Medication reconciliation
• Home safety evaluation
• Caregiver capacity assessment
✔ Required Documentation
• Baseline vitals
• Baseline symptom profile
• Medication list with doses and frequencies
• Safety risks identified
• Caregiver education provided
Red Flags
• Missing admission assessment
• No medication reconciliation
• No home safety evaluation
• No documented caregiver education
VITAL SIGNS & SYMPTOM MONITORING
✔ Required Vital Signs
• Blood pressure
• Heart rate
• Respiratory rate
• Temperature
• Oxygen saturation (if indicated)
• Pain score
✔ Required Symptom Assessments
• Shortness of breath
• Chest pain
• Edema
• Confusion or delirium
• Weakness or dizziness
• GI symptoms (nausea, vomiting, constipation)
✔ Required Monitoring
• Compare to baseline
• Identify trends
• Reassess after interventions
• Notify physician of abnormalities
Red Flags
• No vitals documented
• Abnormal vitals not addressed
• No reassessment after interventions
WOUND CARE & SKIN INTEGRITY
✔ Required Assessment
• Wound size, depth, drainage
• Signs of infection
• Dressing condition
• Skin breakdown risk
• Pressure injury prevention
✔ Required Interventions
• Dressing changes per order
• Offloading and repositioning education
• Infection monitoring
• Physician notification for deterioration
Red Flags
• No wound measurements
• No documentation of infection signs
• Missed dressing changes
• No escalation despite worsening wound
RESPIRATORY & CARDIAC MONITORING
✔ Respiratory Assessment
• Rate and effort
• Lung sounds
• Cough and secretions
• Oxygen use and effectiveness
✔ Cardiac Assessment
• Heart rate and rhythm (if applicable)
• Edema
• Weight trends (CHF patients)
• Chest pain evaluation
✔ Required Monitoring
• Response to interventions
• Need for medication adjustments
• Physician notification for change
Red Flags
• Dyspnea not addressed
• No weight monitoring for CHF
• No escalation for chest pain
MEDICATION SAFETY & ADHERENCE
✔ Required Assessment
• Medication list accuracy
• Correct dosing and timing
• High‑risk medications (insulin, anticoagulants, opioids)
• Side effects
• Missed doses
• Caregiver understanding
✔ Required Interventions
• Medication setup (pillbox, reminders)
• Education on dosing and side effects
• Monitoring after medication changes
• Physician notification for concern
Red Flags
• Medication errors
• No caregiver education
• No monitoring after medication changes
NEUROLOGICAL & COGNITIVE MONITORING
✔ Required Assessment
• Orientation
• Level of consciousness
• Confusion or delirium
• Fall risk
• Behavioral changes
✔ Required Monitoring
• Sudden changes
• Medication effects
• Safety risks
Red Flags
• Confusion not addressed
• No evaluation for reversible causes
• No escalation despite neurological decline
HOME SAFETY & CAREGIVER CAPACITY
✔ Required Safety Assessment
• Fall hazards
• Clutter or unsafe pathways
• Lighting
• Bathroom safety
• Equipment needs (walker, oxygen, hospital bed)
✔ Required Safety Assessment
• Fall hazards
• Clutter or unsafe pathways
• Lighting
• Bathroom safety
• Equipment needs (walker, oxygen, hospital bed)
Red Flags
• Unsafe home environment not addressed
• Caregiver unable to perform tasks
• No documentation of safety education
COMMUNICATION & ESCALATION
✔ Required Communication
• Notify physician of changes in condition
• Document all communication
• Provide clear instructions to caregivers
• Escalate urgent concerns immediately
✔ Required Escalation
• 911 for acute deterioration
• Urgent provider notification for abnormal vitals
• Plan of care updates
Red Flags
• Delayed provider notification
• No documentation of communication
• Failure to escalate despite clear indicators
COMMON BREACH THEMES IN HOME‑HEALTH CARE
• Missed or inadequate assessments
• Missed visits
• Abnormal vitals not addressed
• Medication errors
• Poor communication with physicians
• Failure to escalate
• Unsafe home environment not addressed
• Documentation gaps or contradictions
• No caregiver education
These are the strongest breach indicators in home‑health litigation.