Bag technique procedure format ii

bag technique format and evaluation format for assessment in community setup
prepared by DR. Anjalatchi M.sc(N),MD(AM)

1. BAG TECHNIQUE PROCEDURE FORMAT
IDENTIFICATION OF THE PERSON:
Name of the person:……………………………………………………………………………………….
Age /sex of the person:……………………………………………………………………………………
Education of the person:………………………………………………………………………………….
Occupation of the person:………………………………………………………………………………..
Address of the person:……………………………………………………………………………………...
………………………………………………………………………………………
……………………………………………………………………………………..
Complaints of :……………………………………………………………………………………………...
Community diagnosis:……………………………………………………………………………………..
Name of the procedure:…………………………………………………………………………………….
Date of the procedure:……………………………………………………………………………… ……..
Time of the procedure:…………………………………………………………………………………….
Procedure performed by:………………………………………………………………………………….
Procedure supervised by :………………………………………………………………………………….
Requirements of the procedure:…………………………………………………………………………..
NEEDS AND PROBLEM TO BE ASSESSED BASED ON THE FAMILY REQUIREMENTS:
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GOAL AND OBJECTIVES OF THE PROCEDURE:
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PURPOSE OF THE PROCEDURE:
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PRINCIPLES TO BE FOLLOWED WHILE CARING PROCEDURE:
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LIST OF ARTICLES TO BE REQUIRED WITH RATIONALE:
1.---------------------------------------------------------------------------------------------------------------------------
2. ---------------------------------------------------------------------------------------------------------------------------
3…………………………………………………………………………………………………… .............
4…………………………………………………………………………………………………… .............
5………………………………………………………………………………………………………… .....
6…………………………………………………………………………………………………………… .
7………………………………………………………………………………………………………… ......
8…………………………………………………………………………………………………………… .
9…………………………………………………………………………………………………………… .
10……………………………………………………………………………………………………………
PREPARATION OF THE PERSON AND AR TICLES IN PROCEDURE AREA:

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HOW TO PERFORMED THE PROCEDURE:
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AFTER CARE OF THE PROCEDURE:
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HEALTH EDUCATION RELATED TO PROCEDURE:

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RECORDING AND REPORTING OF PROCEDURE:
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SUMMARY :
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CONCLUSION:
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CHECKLIST FOR BAG TECHNIQUE PROCEDURE:
S.NO: SKILLS PERFORMED BY THE
STUDENTS
MARKS
ALLOTTED
MARKS
OBTAINED
REMARKS

5. 1. Adequate supplies and equipment 1
2. Nursing diagnosis assessment 1
3. Need to be assessed based on family
requirement
1
4. Appropriate to goal/purpose of selection 1
5. Selection of procedure based on
standing order
1
6. Type person selected for procedure 1
7. Explain the procedure to the person 1
8. Spreading and selection of place for
keeping bag
1
9. Way of opening the bag technique 1
10. Hand washing articles taken from bag 1
11. Perform the hand washing in the
community area
1
12. Articles arranged for the procedure
with rationale
1
13. Maintain comfortable during the
procedure for the person as well as
her/him
1
14. Maintain good communication skills
and used scientific knowledge
1
15. Performing allotted procedure 1
16. Assessed the accurate recording
/finding of the procedure
1
17. Discard the waste 1
18. Frequent hand washing 1
19. Replacement of articles to the
compartment of bag
1
20. Folding of newspaper/washing the
hands/replacement of articles
1
21. Health education appropriate to the
procedure
1
22. Summating the procedure 1
23. Conclude the procedure 1
24. Recording the procedure 1
25. Plan for the next visit 1
Total: 25


Signature of the student with date: signature of the supervisor with date:

Signature of the HODS with date: