HOME 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]