MECHANICAL HOME VENTILATION PROGRAM CHECK LIST
FAMILY ASSESSMENT
1. Caretaker demonstrates ability and commitment to learn and participate in patient care. Two
caretakers need to be trained prior to discharge....................................................................... 
2. Sufficient fiscal resources to provide care at home: ability to pay rent, electricity, telephone,
water and out of pocket expenses. Eligible for insurance, community resources and
funding programs for home ventilation ................................................................................... 
3. Demonstrate willingness to cooperate with equipment and home health vendors to maintain a
safe environment in providing home care ................................................................................ 
4. Availability of reliable transportation ...................................................................................... 
5. Adherence to medical regimen and recommendations ............................................................ 
PHYSICAL ENVIRONMENT OF THE HOME
1. Adequate room for home equipment and nursing: patient needs a separate room/space ........ 
2. Meet safety criteria for home: entry and exit access, electric system with grounded outlets,
and working utilities ................................................................................................................ 
3. Home is free of hazards ........................................................................................................... 
4. Environment allows for mobility of equipment ....................................................................... 
5. Adequate light and heating system .......................................................................................... 
6. Oxygen safety in place: 10 feet of any heating device or flames from the patient .................. 
7. Telephone is in working condition to allow 24 hours access to health services...................... 
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CHECK LIST FOR DISCHARGE
It is perfectly normal to feel happy and at the same time anxious when your child is ready to go
home. When you organize your plans early on, the task is much more manageable. The checklist
below summarizes key activities before discharge.
 Projected date of discharge:
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 Status of approval from EPSDT/Insurance:
Authorized.............. 
Still pending ........... 
 You have learned:
CPR ........................ 
Ventilator care ........ 
Tracheostomy care . 
 You have practiced all the home care treatments (including medication)
 You know how to work with all the home care equipment
 You have checked all the ordered equipment and supplies for completeness
 You have completed 24 hour care successfully (including out of room activities)
 Transportation for discharge is arranged
 You have information on the nursing and respiratory companies and their service to
accompany you home on the day of discharge
 Community services information obtained
 Equipment and emergency supplies assembled at bedside 1-2 days before discharge:
Appropriate car seat/child
restraint when applicable ... 
Oxygen ............................... 
Ambu bag ........................... 
Suction machine ................. 
Emergency bag................... 
(to include spare trach tube, suction catheter, normal saline)
 Home care schedule is set: child’s activities, treatments, medications etc
 The house and family are prepared for the child’s discharge
 You have a list of your child’s physicians and specialists
Provided by Childrens Hospital Los Angeles
NOTICE: These documents are not meant to serve as medical advice. Consult with your physician for final medical guidance.
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