Hi Francis, and welcome to Home Dialysis Central. I'm not a PD nurse, but I did a quick PubMed search to see if there were articles on this topic, and there were! A couple of them looked particularly relevant to your needs:
-- Farina J. Peritoneal dialysis: a case for home visits. Nephrol Nurs J. 2001 Aug;28(4):423-8.
I have this article in my office and can fax it to you if you want to either post your fax number, or use our "Contact Us" form to send it to me and remind me what you want (this is probably safer).
-- Nasso L. Our peritonitis continuous quality improvement project: where there is a will there is a way. CANNT J. 2006 Jan-Mar;16(1):20-3. The abstract refers to creation of a home visit form:
Peritonitis was a significant problem for our peritoneal dialysis patients in 2003. In January 2004, we initiated a continuous quality improvement project to address the problem. Our project took 18 months to complete. We developed many action items. Our first step was to analyze the data to ensure accuracy, and also to determine the causative organism that contributed most to the problem. The other steps we took included more education for the home dialysis nurses, creation of a home visit form, revisions to routine doctors' orders, revision of PD education tools, use of specialty materials for high-risk patients, one-time use for all drain equipment, change to peritonitis treatments and, lastly, group education for our patients. After taking all of these steps, there was no improvement to our peritonitis rates after a 12-month period. New action items were developed and included making changes to patient training and developing a home visit protocol. We also created a partnership with our local Community Care Access Centre and taught our community nurses how to help our patients with their peritoneal dialysis. It was after implementing these last changes that we noticed a significant improvement in our peritonitis rates. It was a lengthy and challenging process to go through but in the end, we are very pleased with our results. Not only has this improved the quality of our patients' lives, it has cut costs to our program, and has also helped us to expand our program significantly.
If you want to email the author of that article and ask her about her form, her email address is email@example.com