Nursing Facility Subsequent Visit Note

Date of Service: [Date]

Time: [Time] (Include only if required by workflow)

Facility: [Facility name; unit/room]

Encounter Type: [Subsequent NF/SNF Visit / Other]

Provider: [Provider name, credentials]

Reason for Visit: [Concise one-liner summarizing purpose of visit]

Information Sources: [History sources and reliability] (Specify patient, nursing staff, chart, family; note cognitive or communication limitations if applicable.)

Interval History

(Capture what changed since the last provider visit. Omit elements not applicable. If no significant events, state: "No acute events since last visit.")

• Interval events: [Acute changes, transfers, new infections, wound/device changes]
• Current symptoms: [Symptoms tied to active problems; use patient quotes if meaningful]
• Function & therapy: [Mobility, ADL assist needs, therapy participation, discharge timeline] (Note if therapy notes unavailable.)
• Cognitive/behavior/mood: [Orientation, agitation, sleep, response to interventions] (Include if clinically relevant, especially with psychoactive meds.)
• Nutrition/hydration/bowel/bladder: [Changes or active management only]

Objective

Vitals: [Most recent vitals with 24–72 hour trend; weight trend if pertinent; oxygen requirement] (If unavailable, state brief reason.)

Exam: [Focused exam on systems relevant to active problems: general appearance, cardiopulmonary, mental status, skin/wounds as applicable] (Do not list systems not examined.)

Data: [Key lab abnormalities or trends with dates; imaging/diagnostic results; pending studies; external records reviewed] (Summarize actionable items only.)

Medication Changes: [Medications started/stopped/dose-adjusted since last visit with indication; for high-risk meds document monitoring parameters] (If none: "No medication changes since last visit.")

Assessment & Plan

[Global assessment] (Optional one-sentence summary of overall trajectory and today's priorities.)

[Problem 1]—[improved / stable / worsened / active / new]

• Assessment: [Brief clinical reasoning linking interval history and objective findings; key supporting data; relevant uncertainty]
• Plan: [Medication changes with indication; monitoring parameters and hold instructions; labs/studies to order; nursing/therapy instructions; consults; contingency plan for high-risk situations; follow-up timing]

[Problem 2]—[improved / stable / worsened / active / new]

• Assessment: [Concise rationale and key data]
• Plan: [Actions as above]

(Repeat problem blocks as needed. Order by acuity. Include communication and care coordination—interdisciplinary discussions, family/DPOA updates, discharge planning, transfer decisions—as a problem or within relevant problems when performed.)

Signature

[Electronic signature: Provider name, credentials] — [Date] [Time]

(For unavailable clinically important information, document: "Not available at time of visit" with brief reason. For less important items, omit. Emphasize changes and actionable items; avoid copying large data blocks.)