HOUSE OF HOPE FOUNDATION INC.

UPPER PATALAN, LUMBIA, CAGAYAN DE ORO CITY

SCHOOL:_____________________
DATE & SHIFT:________________
STUDENT OD:_________________
CLINICAL INSTRUCTOR:_______________________

AM CHECKLIST
Activities and Assigned Areas Accomplished Please Check Remarks
1.) Have all the patients done their bathing?
2.) Have the patients done with their morning exercise?
3.) Have you done assisting / doing patients personal hygiene-care?
4.)Have you supervised or helped patients doing assigned household
chores?
NOTE: Items being referred above must be submitted to the House of Hope staff by C.I before therapy at 9:00
A.M
Items being referred below must be submitted to the House of Hope assigned by C.I. before departure at
11:00 A.M
5.) After care:
A). Activity Area: chairs filed one over the other, undo posted
materials and decoration, etc.
Well swept floor
Facilities borrowed (M/F ward, Isolation
Cells), chairs, tables
Other specify
B). Stock Room (Pls. Check the area)
Well ordered clothes, toiletries, etc.
Chemical elements – well arranged and
returned, pls specify
6.) Remember to return all borrowed items: keys, patient’s chart,
microphone/ sound system, ID’s
Others, pls. specify:
7.) Others:
A). Wash Room: kept dry
B). Office/ Nurse station: Personal belongings – claimed
before dismissal (if any)
Checked by: Noted by:

___________________________________ _______________________________________
Clinical Instructor House of Hope Staff

HOUSE OF HOPE FOUNDATION, INC.

UPPER PALALAN, LUMBIA, CAGAYAN DE ORO CITY

SCHOOL:_______________________
DATE & SHIFT:__________________
STUDENT OD:___________________
CLINICAL INSTRUCTOR:___________________________

PM CHECKLIST
Activities and Assigned Areas Accomplished Please Check Remarks
1.) After care: Therapy Area: Chairs filed one over the other
Undo posted materials and decoration,
etc
Well swept floor
Facilities borrowed (M/F ward, Isolation
Cells), chairs, tables
Working area for Medication
Preparation
2.) Have you facilitated the patient’s rosary prayer?
3.) Have all patient’s done their bathing and washing?
4.) Have you done assisting / doing patient’s personal hygiene – care?
5.) Have you supervised or helped patient’s doing assigned household
chores?
6.) After care: Stock room – assess the area for well ordered clothes,
toiletries, etc.
Chemical elements – well arranged & returned, please
specify
7.) Remember to return all borrowed items:
Keys, patient’s chart, microphone/ sound system, ID’s
Others, pls. specify:
8.) Others:
A). Wash Room: kept dry
B). Office/ Nurse station: Personal belongings – claimed
before dismissal (if any)

Note: This checklist must be submitted to the HOH staff.

Signed by C.I before departure @ ________________

Checked by: Noted by:

____________________________________ _______________________________________
Clinical Instructor House of Hope
Staff