Occupational Therapy Home Health Visit Note

Date of Service: [Date]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

Clinician: [Name], [OTR/L / COTA/L]

Time In/Out: [Time in] – [Time out] (Or document total visit time if start/end times not provided)

POC Focus: [Current plan-of-care goals being addressed]

Subjective

[Patient/caregiver report since last visit] (Include changes in function or symptoms, falls, ER/urgent care visits, new medical updates, and current concerns or priorities for today's session. Document pain or fatigue only as relevant to functional performance. Note home program adherence. Use brief direct quotes when they add clinical clarity. If patient is nonverbal or cognitively impaired, specify the information source.)

Objective

(Present an integrated clinical picture of the home visit in narrative form. Omit elements that do not apply. If an area was not assessed due to refusal or safety concerns, state "not assessed" with the reason. Caregiver status should always be documented.)

Home Environment: [Observed barriers and supports] (Entry/exit access, bathroom setup including tub/shower type, toilet height, grab bars; pathway safety, lighting, floor hazards; DME/adaptive equipment present and in use. Include any home modifications completed today.)

Caregiver: [Caregiver status and involvement] (Document who was present and participated, or state [caregiver not present / patient lives alone]. Note observed competence with techniques and any schedule/availability constraints affecting safety or carryover. If caregiver unavailable or patient lives alone, state implications for safety and follow-through.)

Functional Performance: [Activities assessed or trained] (Transfers, ADLs, and/or IADLs addressed; level of assistance, cueing type/frequency, safety observations, and adaptive equipment used. Use agency's assistance scale when available.)

Skilled Interventions: [Interventions and clinical reasoning] (Task analysis, grading or progression, compensatory strategies, safety modifications, device fitting/training. Explain why selected approaches were used and how they addressed functional goals. Include patient/caregiver response and performance changes observed during the session.)

Education/Training: [Topics and method] (Education provided to patient/caregiver, method used [demonstration / verbal instruction / teach-back / handout], and observed learner response/competence. Omit this section if no education occurred.)

Home Program: [Current HEP/occupation-based program] (Exercises or task practice with frequency, safety precautions, supervision needs, and equipment requirements. Note any changes made today with rationale; if unchanged, state that the program was reviewed and competence demonstrated.)

Assessment

[Clinical summary of today's visit] (State response to skilled intervention and progress toward POC goals, referencing specific goals addressed [progressing / partially met / not met]. Identify key barriers and facilitators within the home context. Provide skilled need rationale explaining why continued OT is necessary—complexity, safety judgment, need for progression, caregiver training requirements. Include risk statement when indicated.)

Plan

• [Next visit focus and planned skilled interventions]
• [DME or environmental modifications pending] (Omit if none)
• [Coordination/communication needs] (Omit if none)
• [Emerging discharge criteria/timeline] (Include when discharge is being approached)

Clinician Signature: [Name], [OTR/L / COTA/L]

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