Uniformed Services University of the Health Sciences
Department of Medicine
4301 Jones Bridge Road, C1094
Bethesda, Maryland 20814-4799
Phone: (301) 295-2010
Fax: (301) 295-5792
Use the format below or write in free prose. Either way, please make sure to answer all of the questions. Your final product should be 4-6 typed, single-spaced pages.
1. Please discuss your initial interaction with the patient and/or family. You can use your clinic note or inpatient H/P to answer part of this question. Why was the patient admitted to the hospital (or visiting the clinic)? Why did you choose this patient for a home visit?
2. Discuss your goals and objectives for the home visit.
3. Briefly discuss the home visit. Please specify:
4. State the patient's priorities for health-related quality of life.
5. Briefly discuss your perception of the patient's important medical issues during the home visit. Include a summary of the geriatric assessment techniques that you used and the results of the assessment.
6. Who was the caregiver, and how was the caregiver involved in the patient's life and medical issues?
7. What were the major functional/social issues (was the patient able to care for him/herself, ambulate, able to get medications, transportation, housing, etc) that you noted during the home visit?
8. (if applicable) How has the patient considered or prepared for end of life; i.e., does the patient have a health care proxy or any specific wishes? Has the patient prepared at all for dying? Do not feel obligated to make a plan with the patient; rather encourage the patient to discuss end of life issues with his/her primary physician or primary care provider.
To be completed AFTER the home visit (1-2 pages):
9. Please discuss how this experience affected your concept of elderly patients and medical patients in general?
10. Please discuss how, if at all, this experience has had any impact on you personally or professionally. Did this experience change the way you think of yourself as a doctor? How?
11. Please discuss how, if at all, you believe you had an impact upon your patient and their family.
12. What did you observe about the patient's values and beliefs during your home visit?
IN A SEPARATE COMMUNICATION, IN AN EMAIL OR ON PAPER, please provide us with the name and address of your patient so that we may formally thank him/her.