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Nursing Home Rounds Checklist
Section 1: Overall Wellness Of The Resident
1. 1. Is the resident's overall wellness being checked?
Yes
No
N/A
2. 2. Does the resident have a fever?
Yes
No
N/A
3. 3. Is the resident experiencing shortness of breath?
Yes
No
N/A
4. 4. Does the resident have a cough?
Yes
No
N/A
5. 5. Is the resident showing signs of fatigue?
Yes
No
N/A
6. 6. Does the resident have a sore throat?
Yes
No
N/A
7. 7. What is their pain level?
Section 2: Medication Needs And Administer Medication
1. 1. Is the resident's medication status being reviewed and updated?
Yes
No
N/A
2. 2. Are regular medications being administered as prescribed?
Yes
No
N/A
3. 3. Are PRN (as-needed) medications provided appropriately?
Yes
No
N/A
4. 4. Have any medications been discontinued, and is this documented?
Yes
No
N/A
5. 5. What is the dosage administered?
Section 3: Resident's Vital Signs
1. 1. What is the resident's blood?
2. 2. What is the resident's heart rate?
3. 3. What is the resident's respiratory rate?
4. 4. What is the resident's body temperature?
Section 4: Resident's Medical Records
1. 1. Are updates being made to the resident’s medication records?
Yes
No
N/A
2. 2. Are treatment plans being reviewed and documented?
Yes
No
N/A
3. 3. Are allergies being recorded and updated as needed?
Yes
No
N/A
4. 4. Are assessments being added to the resident’s records?
Yes
No
N/A
5. 5. Is the resident's medical history kept current and complete?
Yes
No
N/A
Section 5: Dietary Needs And Nutrition
1. 1. Are the resident's dietary needs being reviewed?
Yes
No
N/A
2. 2. Is the resident following a vegetarian diet?
Yes
No
N/A
3. 3. Is a low-sodium diet being maintained if required?
Yes
No
N/A
4. 4. Are gluten-free dietary options provided for the resident as needed?
Yes
No
N/A
5. 5. Is a diabetic diet plan being adhered to?
Yes
No
N/A
6. 6. Is a soft diet provided when appropriate?
Yes
No
N/A
7. 7. How is the patient’s appetite?
Section 6: Resident's Physical Therapy Progress
1. 1. What is the resident's mobility?
2. 2. What is the resident's physical strength?
3. 3. What is the resident's range of motion?
4. 4. What is the resident's balance?
5. 5. What is the resident's coordination?
Section 7: Cleanliness And Safety Of Rooms
1. 1. Is the sanitation level in the resident's room inspected?
Yes
No
N/A
2. 2. Are infection control protocols being followed?
Yes
No
N/A
3. 3. Is the lighting in the room adequate?
Yes
No
N/A
4. 4. Are all safety features in the room functioning correctly?
Yes
No
N/A
5. 5. Are any maintenance issues in the room being addressed?
Yes
No
N/A
Section 8: Mental Health Of The Resident
1. 1. Is the resident experiencing anxiety?
Yes
No
N/A
2. 2. Are there signs of depression in the resident?
Yes
No
N/A
3. 3. Is the resident showing signs of confusion?
Yes
No
N/A
4. 4. Does the resident exhibit agitation?
Yes
No
N/A
5. 5. Is the resident withdrawing socially?
Yes
No
N/A
6. 6. What are the resident’s behavioral observations?
Section 9: Dietary Plan
1. 1. Are dietary needs and nutrition reviewed?
Yes
No
N/A
Section 10: Resident Updates
1. 1. Are updates being discussed with the resident?
Yes
No
N/A
2. 2. Have medication changes been communicated to the resident?
Yes
No
N/A
3. 3. Are updates to the treatment plan being explained to the resident?
Yes
No
N/A
4. 4. Have test results been shared with the resident?
Yes
No
N/A
5. 5. Are new interventions being discussed with the resident?
Yes
No
N/A
6. 6. Is the discharge plan reviewed with the resident?
Yes
No
N/A
Section 11: Family Members
1. 1. Are family members being communicated with regarding the resident’s care?
Yes
No
N/A
2. 2. Are the names of family members documented for communication purposes?
Yes
No
N/A
3. 3. Are communication details with family members properly recorded?
Yes
No
N/A
Section 12: Activities For Cognitive Stimulation
1. 1. Are cognitive stimulation activities planned for the resident?
Yes
No
N/A
2. 2. Are puzzles being provided as a cognitive activity?
Yes
No
N/A
3. 3. Is the resident participating in reading groups?
Yes
No
N/A
4. 4. Is art therapy being offered as an activity?
Yes
No
N/A
5. 5. Are trivia games included in the resident’s activities?
Yes
No
N/A
6. 6. Is music therapy being used for cognitive stimulation?
Yes
No
N/A
Section 13: Nursing Staff Shifts
1. 1. Are nursing staff shifts assigned properly?
Yes
No
N/A
2. 2. Is staff availability considered during shift assignments?
Yes
No
N/A
3. 3. Is staff expertise being factored into shift planning?
Yes
No
N/A
4. 4. Are workloads distributed evenly among the staff?
Yes
No
N/A
5. 5. Is continuity of care ensured through appropriate shift assignments?
Yes
No
N/A
6. 6. Are staffing concerns addressed during shift assignments?
Yes
No
N/A
Section 14: Emergency Systems
1. 1. Are emergency systems being monitored regularly?
Yes
No
N/A
2. 2. Are emergency call buttons checked for functionality?
Yes
No
N/A
3. 3. Are fire alarms tested for proper operation?
Yes
No
N/A
4. 4. Are safety devices being inspected?
Yes
No
N/A
5. 5. Are system malfunctions identified and addressed?
Yes
No
N/A
6. 6. Are maintenance requirements for emergency systems being fulfilled?
Yes
No
N/A
Section 15: Medical Appointments
1. 1. Are necessary medical appointments facilitated for the resident?
Yes
No
N/A
2. 2. Are the details of the appointment documented?
Yes
No
N/A
3. 3. Is the date of the appointment set and communicated?
Yes
No
N/A
4. 4. Are transportation arrangements made for the resident?
Yes
No
N/A
Section 16: Physical Therapy Progress
1. 1. Is the resident’s progress in physical therapy being evaluated?
Yes
No
N/A
Section 17: Privacy And Patient Rights
1. 1. Are privacy and patient rights being respected?
Yes
No
N/A
2. 2. Is confidentiality maintained in all aspects of the resident’s care?
Yes
No
N/A
3. 3. Is informed consent obtained from the resident for medical decisions?
Yes
No
N/A
4. 4. Is the dignity of the resident preserved during care?
Yes
No
N/A
5. 5. Is the resident’s autonomy supported?
Yes
No
N/A
6. 6. Is a patient advocate involved when necessary?
Yes
No
N/A
Section 18: Interdisciplinary Team
1. 1. Is the resident’s care being discussed with the interdisciplinary team?
Yes
No
N/A
2. 2. Is the physician involved in care discussions?
Yes
No
N/A
3. 3. Is the nurse contributing to interdisciplinary team meetings?
Yes
No
N/A
4. 4. Is the physical therapist included in the care discussions?
Yes
No
N/A
5. 5. Is the occupational therapist participating in the planning?
Yes
No
N/A
6. 6. Is the psychologist consulted during care discussions?
Yes
No
N/A