Home/Residence Visit Note

Date: [Encounter date]

Patient: [Patient name and identifier]

Provider: [Provider name, credentials]

Setting: [private home / assisted living / group home / custodial facility / other residence type]

Participants Present: [Patient and others present with names/roles]

Consent: [Patient agreement or non-objection to discussion with those present; if patient lacks capacity, note basis for surrogate involvement]

History Sources: [patient / caregiver / facility records / other]

Subjective

[Chief concern, interval history, and patient experience] (Summarize in one coherent paragraph. Attribute collateral clearly, e.g., "Per [name/relationship]..." Include functional status relevant to today's concerns—ADLs, mobility, falls history—and medication management observations: who manages medications, organization method, adherence barriers, and high-risk medication concerns. Use brief direct quotes only for safety-critical statements.)

Objective

Vitals: [Values with source if not clinician-measured] (If not obtained, state why and plan to obtain.)

Exam: [Pertinent findings by system] (Note limitations due to home setting if applicable.)

Environment/Safety: [Objective observations of fall hazards, bathroom safety, lighting, medication storage, DME condition/fit, and general home conditions relevant to care] (State facts only; save interpretation for Assessment.)

Medication Reconciliation: [Sources reviewed, discrepancies identified, items unable to verify, plan to resolve] (If not completed, state why and plan to obtain.)

Assessment

(Provide a problem-oriented synthesis linking home observations, collateral, and exam findings to clinical reasoning. List each problem with current status and key supporting evidence including environmental and social factors.)

[Problem 1]: [Diagnosis or clinical issue] — [stable / improving / worsening]. [Assessment statement tying findings to clinical impression.]

[Problem 2]: [Diagnosis or clinical issue] — [stable / improving / worsening]. [Assessment statement.] (Add problems as needed in order of priority.)

Plan

(Organize by problem. For each, include relevant diagnostics/monitoring, medication changes with rationale, safety actions tied to environment findings, patient/caregiver education provided, referrals and services ordered, and follow-up timing.)

[Problem 1]: [Diagnostics, medication changes, safety interventions, education, referrals, follow-up]

[Problem 2]: [Plan elements as relevant] (Add problems as needed.)

Contingency: [Instructions for when to contact provider, seek urgent care, or call emergency services; include thresholds and red flags]

Time-Based Billing: [Total clinician time in minutes, excluding travel] — [Qualifying activities] (Include only if billing by time.)

(Omit sections not performed. For safety-critical items not obtained—vitals, medication reconciliation—explicitly state reason and plan to obtain.)