A home health visit note records one skilled nursing visit in the patient’s home: why a nurse was needed, what you found and did, what you taught, how safe the home is, and the plan for the next visit. Copy the free template, see a heart failure and a hip surgery example, and check what home health and home care documentation needs in each part.
Blank home health visit note template
FreeHOME HEALTH VISIT NOTE Patient: [Name, date of birth] Date of visit: [Date] Time in and time out: [Times, and total minutes] Visit type: [Start of care, routine visit, extra visit for a change, first visit after a hospital stay, or discharge visit] Visit number: [This visit, and the frequency ordered] Ordering clinician: [Name, role, phone] Nurse: [Name, credentials] Others present: [Caregiver, family, interpreter, or none] REASON FOR CARE Primary diagnosis: [The condition home care is treating, and the date of any recent hospital stay] Skilled need today: [What needed a nurse this visit: assessing a change, wound or line care, an injection, a lab draw, or teaching not yet learned] Homebound status or reason care is at home: [Where your agency or payer requires it: how far the patient can walk, the device and help needed, breathlessness, pain, confusion, stairs, and how often and why they leave home] Since the last visit: [Symptoms, falls, emergency visits, appointments, and new medicines, as reported by the patient and caregiver] VITAL SIGNS AND MEASURES Vital signs: [Temperature, pulse, BP and position, RR, SpO2 on room air or oxygen and flow] Weight: [Today's weight, the last weights, and the change, on the same scale] Pain: [Site, score and scale, what helps] Home readings: [Blood sugar, BP, or weight log reviewed, or not applicable] Call parameters: [The ranges the ordering clinician set, and whether any were crossed] FOCUSED ASSESSMENT Systems assessed: [The systems tied to the diagnosis and today's complaints] Findings: [What you found, compared with the last visit] Mental status and mood: [Alert, oriented, any change from baseline] Intake and elimination: [Appetite, fluids, bowels, bladder] MEDICATIONS Review: [Every bottle, blister pack, and over-the-counter product in the home, checked against the current list] Discrepancies: [Old doses, duplicates, missing or stopped medicines still in use, or none] Adherence: [How doses are organized and taken, missed doses, and why] Side effects: [Any found, or none] CARE GIVEN Procedures: [Wound, line, drain, or catheter care, injection, lab draw, or staple removal: what, where, and how it was tolerated] Supplies: [Used, and left in the home] TEACHING Topic and learner: [What was taught, and to whom] Method: [Explanation, demonstration, or a written guide in the patient's language] Teach-back: [What the patient or caregiver said or showed back, and what needs repeating] HOME SAFETY AND FALL RISK Fall risk: [Score and the tool your agency uses, and any falls since the last visit] Home: [Lighting, rugs, stairs, bathroom, cords, pets: hazards found and what was changed] Equipment: [Walker, commode, grab bars, hospital bed, or oxygen: in place and used safely] Emergency plan: [Phone in reach, personal alarm, who to call] CAREGIVER Main caregiver: [Name, relationship, when they are there] What they can do: [Care they give now, and what they are learning] Strain: [Sleep, health, signs of strain, and help offered] RESPONSE TO THE PLAN Goals: [Each goal from the plan of care: met, progressing, or not progressing, with the evidence] Barriers: [What is getting in the way] COMMUNICATION Ordering clinician: [Name, time, how reached, what you reported] Orders received: [New or changed orders, read back and confirmed, or none] Care team: [Therapist, aide, social worker, pharmacy, or family updated] PLAN FOR NEXT VISIT Next visit: [Date, and the visits left in the frequency ordered] Focus: [What to check, do, or teach next time] When to call: [Signs to call the agency about, and when to call 911] Discharge from visits: [The goals that will end nursing visits, and the expected date] Signed: [Nurse name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Home health nursing visit, 6 days after hospital discharge, 70 minutes
Helen Brooks, born March 3, 1946, 80 years old. November 10, 2026. Time in 10:05, time out 11:15, 70 minutes. Routine skilled nursing visit, 3 of 9 ordered: 3 a week for 1 week, then 2 a week for 3 weeks. Ordering clinician: Priya Shah, NP, heart failure clinic. Nurse: Grace Kim, RN. Present: her son Daniel, from 10:45.
Heart failure with reduced ejection fraction, LVEF 30% on the echo during her admission. In hospital 8 days for fluid overload; discharged November 4 at a weight of 69.6 kg (153 lb). Skilled need today: assess fluid status after the admission, check her medicines against the discharge list, and teach daily weights and low-salt eating. Reason care is at home, as her agency requires: short of breath after about 10 m with her 4-wheeled walker; needs her son to drive and to help her on the 4 front steps; leaves home only for medical appointments. Since the last visit on November 7: ankles more swollen for 2 days; now sleeping on 3 pillows, up from 1; woke short of breath once last night and sat in her chair until it passed. No chest pain, fainting, or falls. No emergency visits.
T 36.6 °C (97.9 °F), HR 88 regular, BP 132/78 sitting, RR 22, SpO2 92% on room air at rest, 95% at discharge. Weight on her own bathroom scale, before breakfast and after voiding: 71.4 kg (157 lb), up from 69.6 kg on November 7: a gain of 1.8 kg (4 lb) in 3 days. No weights logged on November 8 or 9; she thought once a week was enough. Call parameters on the plan of care: a gain of 1.5 kg (3 lb) in 3 days or 2 kg (5 lb) in a week, SpO2 below 90%, or systolic BP below 90 or above 160. The weight parameter is crossed. Fine crackles at both lung bases, clear on November 7. Neck veins distended with her head raised to 45 degrees. Pitting edema 2+ to mid-shin in both legs, trace at the last visit. Stopped once to rest walking 6 m from the kitchen to her chair. Alert and oriented, no change from baseline. Passing less urine, by her report. Eating canned soup and deli ham sandwiches most days since discharge “because they’re easy.”
Every bottle in the home checked against the November 4 discharge list. Discrepancy: furosemide is listed as 40 mg each morning, but she has taken 1 tablet a day from her old bottle of furosemide 20 mg, her dose before the admission. The new 40 mg bottle was unopened in the pharmacy bag. Over-the-counter naproxen 220 mg in the bathroom, taken twice this week for knee pain. Matched the list: metoprolol succinate 50 mg daily, sacubitril-valsartan 24/26 mg twice daily, spironolactone 12.5 mg daily, and dapagliflozin 10 mg daily, all taken from her weekly pill organizer with no missed doses. No dizziness on standing.
After the call below, set up the pill organizer with the new furosemide doses, with her son watching. With her agreement, the old 20 mg bottle and the naproxen bagged for return to the pharmacy. Taught both of them: weigh every morning on the same scale after voiding and before breakfast, write it on the log on the fridge, and call the agency for a gain of 1.5 kg in 3 days, more swelling, or waking short of breath. Second furosemide dose at 14:00, not later, so she isn’t up at night. Low-salt eating: read the sodium on labels; canned soup and deli meats are the main sources this week. Acetaminophen, already on her list, for knee pain, never naproxen or ibuprofen. Teach-back: she weighed herself and wrote it in the log correctly, and named weight gain and swelling as reasons to call; needed a prompt for waking short of breath. Her son named the reasons to call 911: chest pain, breathlessness at rest that doesn’t settle sitting up, or fainting.
Timed Up and Go 19 seconds with her walker; 12 seconds or more flags fall risk. Twice-daily furosemide will mean more trips to the bathroom: hallway throw rug removed, with her agreement; night lights already in place; walker kept by the bed. Bedside commode offered; she declined for now. No falls. Phone on her walker tray. Lives alone. Her son visits every evening and does her shopping; he will come each morning this week to check her weight. He asked about meal delivery: referral sent to the agency social worker.
Goal of a weight within 1 kg of 69.6 kg: not met. Goal of taking medicines as listed: not met before today; the furosemide dose corrected at this visit. 10:50: called Priya Shah, NP, by phone, using SBAR: weight up 1.8 kg in 3 days, 2+ edema, crackles at both bases, SpO2 92%, needing 3 pillows, furosemide 20 mg taken in place of 40 mg, and naproxen twice this week. Orders, read back and confirmed: furosemide 40 mg by mouth twice daily, at 08:00 and 14:00, for 3 days, then 40 mg once daily; stop naproxen; electrolytes and creatinine drawn at the next visit; an extra nursing visit on November 12; heart failure clinic visit moved up to November 17. Next visit November 12: weight, edema, lungs, BP, dizziness on standing, the pill organizer, and the blood draw. Call 911 for chest pain, breathlessness at rest, or fainting. Discharge from visits when her weight is stable for 2 weeks and she manages her weights and medicines on her own, about 3 weeks from now. Signed: Grace Kim, RN, November 10, 2026, 11:40.
Home care nursing visit, day 14 after hip surgery, wife learning his care, 65 minutes
George Lindqvist, born July 21, 1949, 77 years old. November 10, 2026. Time in 13:30, time out 14:35, 65 minutes. Routine nursing visit, 4 of 8 ordered: 2 a week for 4 weeks. Ordering clinician: his family physician, with the orthopedic surgeon’s orders for the incision. Nurse: Tom Becker, RN. Present: his wife Linda, his main caregiver.
Right hip hemiarthroplasty on October 27 for a femoral neck fracture after a fall at home; posterior approach, with hip precautions for 6 weeks. Home on November 2. A stage 2 pressure injury on the right heel was found on day 4 in hospital. Skilled need today: staple removal as the surgeon ordered, heel wound assessment and care, and teaching his wife the dressing change and heel offloading. Reason care is at home, as the agency requires: walks about 10 m with a walker and someone beside him; can’t manage the 6 entry steps without 1 person helping; leaves home only for appointments. Since the last visit on November 6: no falls. Hip pain 3/10 at rest and 5/10 walking. No bowel movement for 4 days. The physical therapist visited on November 8.
T 36.9 °C (98.4 °F), HR 76 regular, BP 126/72 sitting and 120/70 standing with no dizziness, RR 16, SpO2 96% on room air. Pain 3/10 on the numeric scale. Incision: 14 cm, right posterolateral hip, 22 staples; edges together, dry, with no redness, swelling, or drainage. Calves soft and not tender, with no swelling. Right heel: stage 2 pressure injury, 1.2 × 1.0 cm, area 1.2 cm², down from 1.8 × 1.4 cm, 2.5 cm², on November 3. Pink, moist, partial thickness, no slough; small serous drainage; skin around it intact. Left heel and sacrum intact. Braden 16, mild risk. Abdomen soft, mildly distended, bowel sounds present, passing gas, no nausea. Alert and oriented. Sleeping in his recliner on some nights.
Medicines in the home checked against the discharge list: all matched except senna. Enoxaparin 40 mg under the skin daily at 18:00 until November 24, given by his wife. Acetaminophen 1,000 mg three times a day. Oxycodone 5 mg as needed; using 2 a day. Senna was on the list as needed but was never bought. Constipation from the oxycodone, with no laxative taken.
All 22 staples removed as the surgeon ordered; adhesive strips applied; the incision stayed closed. Heel cleansed with saline and a silicone foam heel dressing applied, to be changed every 3 days or when loose or soiled. His wife then did the dressing change herself, supervised: correct after 1 prompt to lift the border slowly, not pull it. Heel offloading taught: a pillow lengthwise under the calf so the heel floats free of the bed, and the offloading boot at night. Hip precautions reviewed: no bending the hip past 90 degrees, no crossing the legs, no turning the right foot inward. Teach-back: he named all 3 precautions; his wife showed the pillow position and named the signs to call about.
Morse Fall Scale 65, high risk, on the agency’s tool: a fall last month, more than one diagnosis, a walker, and a weak gait. Bed moved to the main floor; raised toilet seat, grab bar, and shower chair in place; night light on the way to the bathroom. Walker within reach of the recliner and the bed. No falls. His wife, 75, gives all his care and helps him to the toilet 2 or 3 times a night; sleeping 4 to 5 hours, and tearful once during the visit. Their daughter lives 2 hours away and comes on weekends. His wife agreed to a care aide for showers twice a week; request sent to the agency.
Incision goal met. Heel wound progressing: area down by half in 1 week. Goal of his wife changing the dressing on her own: progressing, 1 prompt. Pain controlled. New problem: constipation. 14:20: called his family physician’s office and reported to the practice nurse: no bowel movement for 4 days on oxycodone, senna not started. She relayed the physician’s orders, read back and confirmed: senna 2 tablets at bedtime and polyethylene glycol 17 g daily, holding both for loose stools. Message to the surgeon’s office: staples removed on day 14, incision closed and dry; follow-up on November 20 confirmed. Physical therapist updated by message. Next visit November 13: heel dressing, bowels, and a second return demonstration by his wife with no prompts. Call the agency for redness, drainage, or opening of the incision, a temperature of 38 °C (100.4 °F) or higher, calf pain or swelling, a heel wound that gets larger, darker, or starts draining, or no bowel movement by November 12. Call 911 for chest pain, sudden shortness of breath, or sudden severe hip pain with the right leg looking shorter or turned. Discharge from visits when the heel has closed and his wife manages the care on her own, expected around November 24. Signed: Tom Becker, RN, November 10, 2026, 15:00.
When the visit happened, what kind it was, and why it needed a nurse. The skilled need is the line a reviewer looks for first.
Avoid: “Routine visit, patient stable.” Name what needed a nurse’s skill this time, or why the visit was made.
The numbers and findings for the problems home care is treating, set against the last visit and the call parameters on the plan of care. The start-of-care assessment your agency uses is the baseline; each visit looks at what changed.
Avoid: A reading with no comparison. A weight of 71.4 kg means little until it sits next to 69.6 kg three days ago.
What is actually in the home and how it is being taken, checked against the current list. Home is where the gaps after a hospital stay show up.
Avoid: Checking the list instead of the bottles. The discharge list can be right while the patient takes pills from an old bottle.
The procedures done at the visit, and what the patient or caregiver learned, shown in their own words or hands.
Avoid: “Taught low-salt diet.” Write what the patient said back, and what you will check next time.
Whether the home is safe for this patient now, and whether the person helping can keep going.
Avoid: A fall risk score with no change to the home. Record what was moved, added, or agreed.
Progress on each goal in the plan of care, who you told, what they ordered, and what the next nurse needs to do.
Avoid: “Clinician notified.” Write who, when, what you reported, and what was ordered.
A note that lists vital signs and “stable” doesn’t show why a nurse came. Say what needed your skill: a change to assess, a procedure, or teaching that isn’t learned yet.
Time in and time out should fit the care you wrote. A 20-minute visit with staple removal, a dressing change, and teaching for two people invites questions.
Patients nod. Ask them to say or show it back, and record what they got right and what you will repeat at the next visit.
One sentence copied forward stops meaning anything. Describe today: how far the patient walked, the help they needed, and how they felt after.
If a weight, BP, or blood sugar is outside the range on the plan of care, record that you called, when, what you reported, and what was ordered.
Vero Scribe writes the home health visit note in your template from the visit, with the patient’s consent, or from your dictation in the car afterward. You review and edit every section, then copy it into your agency’s record or export it to Word or PDF. Vero works in 60+ languages.
Start with the visit type and your time in and out. Name the skilled need: why this visit needed a nurse. Record vital signs and weight against the call parameters, a focused assessment compared with the last visit, a medication review against the bottles in the home, the care you gave, and what you taught, with the teach-back. Then add home safety, the caregiver, progress on each goal, who you called and what they ordered, and the plan for the next visit.
For each visit: the date, time in and out, and visit type; the skilled need; the reason care is at home, where your agency or payer requires it; vital signs and a focused assessment; a medication review; care given; teaching and teach-back; home safety and fall risk; the caregiver; progress toward the goals; communication with the ordering clinician; and the next visit. Home care agencies use the same parts, whatever they call the note.
Where your agency or payer requires it, describe what makes leaving home hard, in that day’s facts: how far the patient can walk, the device and help they need, breathlessness, pain, confusion, or stairs, and how often they go out and why. “Homebound” alone doesn’t say why. “Short of breath after 10 m with a walker; needs her son on the 4 front steps; leaves home only for medical appointments” does.
The start-of-care assessment your agency uses is the full first assessment: history, every system, function, the home, and the goals that become the plan of care. A visit note records each visit after that. It focuses on the problems in the plan, compares today with the last visit, and shows why a nurse was needed this time. Repeat the full assessment when your agency asks, such as after a hospital stay.
Yes. Copy it, or download it as a Word or text file. No account needed.
System-by-system nursing assessment with pressure injury and fall risk, lines and drains, and escalation.
The shift note: assessment, timed vital signs and interventions, the response, provider calls, teaching, and the plan for the next shift.
Assessment data, nursing diagnosis, SMART outcomes, interventions with rationale, and evaluation, one diagnosis at a time.
The bedside handoff in I-PASS order: severity, systems, lines, meds due, pending labs, risks, to-dos, and read-back.
Focus charting in four parts: the focus, the data behind it, nursing actions, and the timed patient response.
Skilled visit notes drafted from the visit, for you to review.
Nursing notes, SBAR calls, and teaching records, drafted for your review.
Scoring pressure injury risk from 6 to 23, and the steps that follow.
The fall risk score, its cutoffs at 25 and 45, and the precautions.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.