Home Health Skilled Nursing Visit Note (OASIS-Driven)

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN/Patient ID: [Identifier]

Service Address: [Street, City, State, ZIP]

Visit Date: [MM/DD/YYYY]

Time In / Time Out: [HH:MM] / [HH:MM]

Visit Type: [Routine / PRN / Supervisory / Recert-related / ROC-related]

Clinician Name & Credentials: [Name, Credentials]

Certification Period: [MM/DD/YYYY] to [MM/DD/YYYY]

Ordering/Referring Provider: [Provider name and contact]

Primary Diagnosis: [ICD-10 code and description]

Secondary Diagnoses: [ICD-10 codes and descriptions]

Reason for Visit & Skilled Focus

[Brief narrative of visit purpose and skilled interventions planned, aligned to ordered services] (1–4 sentences; state skilled focus such as assessment of unstable condition, complex wound care, medication reconciliation/teaching, symptom management. This section must not be omitted.)

Problems Addressed: [wound/skin / medication management / cardiopulmonary / diabetes / catheter/ostomy/tube / neuro / safety/falls / caregiver training / other] (Select all that apply.)

Homebound Status

Criterion 1: [supportive device required / special transportation / requires another person / leaving home medically contraindicated]

Criterion 2: [normal inability to leave home AND leaving requires considerable effort]

Absences: [Frequency and purpose of absences from home, or "None"]

Supporting Details: [Patient-specific narrative describing functional, medical, cognitive, and environmental factors limiting leaving home; include assistance required, distance tolerance, symptom triggers with objective data, and safety barriers]

(If homebound status cannot be assessed today, document the limitation and data source used; outline follow-up plan.)

Subjective

Patient-reported since last visit: [Symptoms including pain score, dyspnea, edema, dizziness, appetite, bowel/bladder, sleep, mood; medication adherence and understanding; new or worsening symptoms; utilization such as ED, hospital, or MD visits and new orders] (Use direct quotes when clinically meaningful. If not obtained, state reason.)

Caregiver-reported since last visit: [Observations, concerns, barriers, changes in supports or routines] (Label caregiver role. If no caregiver involved, state "No caregiver involved.")

Objective

Vitals: [BP with position, HR, RR, Temp with method, SpO₂ on room air or with O₂ flow, pain score with location, weight if indicated] (If any vital not obtained, state reason.)

General: [Level of distress, orientation, affect, appearance]

Exam Findings: [Pertinent positives and negatives by relevant system—cardiopulmonary, neurologic, GI/GU, integumentary, musculoskeletal as applicable to active problems]

Wound Assessment: [For each wound: location, type/etiology, measurements L×W×D in cm, wound bed description with tissue percentages, exudate amount/color/odor, peri-wound condition, pain with care, infection signs present or absent, staging if applicable, dressing on arrival, supplies status] (If no wounds, state "No open wounds" or reason for deferral. Repeat format for each wound.)

Functional Status: [Transfers, gait, assistive devices, balance, endurance, fall risk, ADL/IADL assistance level with objective performance measures]

Environment/Supports: [Caregiver availability and competence, medication storage, DME/oxygen status, home safety hazards]

Medications: [Reconciliation results, changes since last visit, high-risk medication monitoring, adherence barriers, source of med list, discrepancies resolved]

Assessment & Plan

(Organize by active problem in descending clinical risk order. Repeat the following structure for each problem addressed today.)

[Problem Name]

Status: [Brief clinical summary of today's findings; changes versus last visit or baseline]

Skilled Need: [Patient-specific reason skilled nursing is required] (Document why this requires nursing judgment, not routine care.)

Interventions: [What was done, technique details, supplies used, patient tolerance, immediate response] (If ordered intervention not performed, document reason and safety actions taken.)

Teaching: [Topic] via [verbal / written / demonstration] to [patient / caregiver]; Teach-back: [accurate / partial / unable]; Barriers: [none / specify]; Reinforcement plan: [next steps]

Progress: [Reference POC goal, objective measure such as wound size trend, pain trend, weight, SpO₂, or functional performance] — [improving / stable / declining] (If not progressing, state barriers and plan adjustments.)

Coordination: [Provider notifications, new or changed orders, communication with other disciplines, supplies ordered]

Next Visit Plan: [Anticipated date and frequency, primary focus, specific follow-ups such as labs, teaching reinforcement, or re-measurements]

Disposition

[Patient status at end of visit, safety check completed, persons present, instructions provided] (If unsafe at departure, document steps taken and escalation.)

Signature

Clinician Signature: [Full name, credentials]

Date/Time Signed: [MM/DD/YYYY HH:MM]

(Late entries or addenda must be labeled as such with date and time created.)