Chapter 19: Visit Forms

Overview

Visit forms are the clinical documentation tools that clinicians use to record what happened during each patient visit. Each discipline (Skilled Nursing, LPN/LVN, HHA, PT, OT, SLP, MSW) has its own specialized form tailored to the services they provide. This chapter explains how visit forms are accessed, completed, and what makes HHA visits unique.

What You'll Learn

How visit forms are created from scheduled visits
Overview of all visit form types by discipline
Detailed explanation of HHA Visit Notes (requires active HHA Care Plan)
Detailed explanation of HHA Supervisory Visits
Common workflow for completing and reviewing visits
Integration with QA review process

19.1 How Visit Forms Are Created

From Scheduled Visits

Visit forms don't exist in isolation - they're always connected to a scheduled visit:

Visits Are Scheduled in the Schedule Center or Care Order
Clinician Opens the Visit from My Day or My Schedules
Form Opens based on the visit type (SN Visit, HHA Visit, PT Visit, etc.)
Clinician Completes Documentation during or after the visit
Form Is Saved and Submitted for QA review

Visit Type Determines Form Type

When a visit is scheduled, the system automatically determines which form to use based on:

Discipline (RN, LPN, HHA, PT, OT, SLP, MSW)
Visit Type configured in Visit Type Setup
Form Template associated with that visit type

Example:

Schedule a "Skilled Nursing Visit" → Opens SN Visit Note form
Schedule an "HHA Visit" → Opens HHA Visit Note form
Schedule a "Physical Therapy Visit" → Opens PT Visit Note form

19.2 Overview of Visit Form Types

The system provides specialized forms for each discipline:

Skilled Nursing Visit Note

Used By: RN (Registered Nurse)
Purpose: Document skilled nursing interventions, assessments, treatments
Key Sections: Visit Info, Systems Assessment, Medications, Wound Care, Vital Signs, Clinical Narrative
Typical Duration: 30-60 minutes per visit

LPN/LVN Visit Note

Used By: LPN (Licensed Practical Nurse) or LVN (Licensed Vocational Nurse)
Purpose: Document licensed nursing care under RN supervision
Key Sections: Similar to SN but may have restricted sections based on state scope
Typical Duration: 30-45 minutes per visit

Physical Therapy Visit Note

Used By: PT (Physical Therapist)
Purpose: Document therapy interventions, progress toward goals, exercise programs
Key Sections: Visit Info, Functional Assessment, Interventions, Progress Notes, Home Exercise Program
Typical Duration: 45-60 minutes per visit

Occupational Therapy Visit Note

Used By: OT (Occupational Therapist)
Purpose: Document ADL training, adaptive equipment, cognitive/perceptual interventions
Key Sections: Visit Info, ADL Assessment, Interventions, Equipment/Modifications, Progress Notes
Typical Duration: 45-60 minutes per visit

Speech Language Pathology Visit Note

Used By: SLP (Speech Language Pathologist)
Purpose: Document speech, language, swallowing, cognitive-communication interventions
Key Sections: Visit Info, Communication Assessment, Swallowing Assessment, Interventions, Progress Notes
Typical Duration: 45-60 minutes per visit

Medical Social Worker Visit Note

Used By: MSW (Medical Social Worker)
Purpose: Document psychosocial assessments, counseling, resource coordination
Key Sections: Visit Info, Psychosocial Assessment, Interventions, Resources/Referrals, Progress Notes
Typical Duration: 30-60 minutes per visit

Home Health Aide Visit Note ⭐

Used By: HHA (Home Health Aide)
Purpose: Document personal care, homemaking, and task completion from HHA Care Plan
Key Sections: Visit Info, Care Plan Tasks, Vital Signs, Visit Narrative
Special Requirement: Active HHA Care Plan MUST exist before HHA can complete visit
Typical Duration: 30-120 minutes per visit (varies by care plan)
Detailed Documentation: See Section 19.3 below

HHA Supervisory Visit ⭐

Used By: RN or LPN conducting supervisory oversight of HHA
Purpose: Evaluate HHA competency, assess care quality, review care plan adherence
Key Sections: HHA Selection, Competency Evaluation, Performance Checklist, Supervisory Narrative
Regulatory Requirement: Required every 2 weeks by Medicare
Detailed Documentation: See Section 19.4 below

19.3 HHA Visit Note (Detailed)

Understanding HHA Visits

HHA (Home Health Aide) visits are unique because they're task-driven rather than assessment-driven. HHAs provide personal care and light homemaking services based on a pre-defined care plan.

Critical Requirement: Active HHA Care Plan

Before an HHA can complete any visit, an Active HHA Care Plan MUST exist for that patient's care order.

Why This Matters:

HHA visits are guided by the active care plan's task list
The system loads tasks from the care plan into the visit form
Without a care plan, the HHA has no defined scope of work
The visit form will block completion if no active care plan exists

What You'll See:

If no active care plan exists, the form displays: "No active HHA Care Plan found for this patient. Please create a care plan in the OASIS assessment."
All action buttons (Save, Review, Complete) are disabled until a care plan is available

How HHA Visits Load Tasks from Care Plan

When an HHA opens the visit note:

System Fetches Active Care Plan: Automatically retrieves the active HHA Care Plan for the patient's care order
Tasks Are Loaded: All tasks from the care plan appear in the "Today's Care Plan" section
Vital Sign Parameters Are Loaded: If the care plan includes vital sign safety ranges, they're displayed
Additional Sections Are Loaded: Safety precautions, functional limitations, and activities permitted are shown as read-only reference

Example:

Care Plan has 8 tasks (5 Daily, 3 Weekly)
HHA opens visit on Monday
All 8 tasks appear in the visit form
HHA marks each task as "Completed," "Not Done," or "Refused"

HHA Visit Note Sections

1. Visit Information

Visit Date: Date of the visit
Travel Start/End Time: For mileage tracking
Associated Mileage: Distance traveled to/from patient home
Surcharge: Any additional charges (e.g., weekend, after hours)
Last BM Date: Important for monitoring bowel patterns

2. Today's Care Plan (Task Completion)

This is the core section where HHAs document what they did.

For Each Task:

Task Description: Loaded from the care plan (e.g., "Bathing assistance")
Category: Task category (e.g., "Personal Care")
Frequency: Daily or Weekly (informational)
Status: HHA selects one:
- Completed: Task was done successfully
- Not Done: Task was not performed (HHA should explain why in narrative)
- Refused: Patient refused the task

Task Status Colors:

Completed: Green chip
Not Done: Gray chip
Refused: Orange chip

Best Practice: HHAs should complete ALL tasks unless there's a valid reason. If "Not Done" or "Refused," explain in the Visit Narrative.

3. Vital Signs (Optional)

If the care plan includes vital sign parameters, they appear here:

Available Fields:

Temperature (°F)
Pulse (bpm)
Respiration (per min)
Blood Pressure (Systolic/Diastolic)
O2 Saturation (%)
Blood Glucose (mg/dL)
Weight (lbs)

Safety Alerts:

If the care plan has parameters set (e.g., BP 100-140/60-90)
AND the HHA enters a value outside that range
The system may show a warning (depending on agency settings)
HHAs should note out-of-range vitals in the narrative and notify the RN

4. Visit Narrative

Free-text field for HHAs to document:

General Observations: How the patient looked, mood, behavior
Task Details: Specific notes about tasks performed
Patient Statements: Any concerns or complaints from patient/family
Issues or Changes: Falls, skin changes, appetite changes, confusion, etc.
Communication: What was communicated to family or RN

Example Narrative:

Patient alert and oriented. Assisted with shower - patient steady with grab bars. 
Changed bed linens and laundered 2 loads. Patient ate well at breakfast. 
Noted small reddened area on left heel - informed RN via text. Patient's daughter 
called and I updated her on visit. Patient in good spirits today.

5. Additional Sections (Read-Only Reference)

These sections are loaded from the care plan for the HHA's reference:

Safety Precautions: Reminders (e.g., "Fall Precautions," "O2 Precautions")
Functional Limitations: Patient's limitations (e.g., "Hearing," "Ambulation")
Activities Permitted: What patient can do (e.g., "Walker," "Up as tolerated")
Comments: Any special instructions from the care plan

HHAs can view these but cannot edit them - they're informational only.

Completing the HHA Visit

Fill Out All Required Fields:
- Visit date and times
- Mark status for ALL tasks
- Enter vital signs (if required by agency or care plan)
- Write a narrative
Click "Save Document":
- Saves progress as Draft
- Can return later to continue
Click "REVIEW":
- Puts form in read-only review mode
- HHA can double-check all entries
- Click "CANCEL REVIEW" to edit again
Click "COMPLETE VISIT":
- Opens signature modal
- HHA enters password to sign
- Visit is submitted for QA review
- Status changes to "Pending Review"

What Happens After Completion

Visit document is created with status "Pending Review"
Appears in QA Center for RN review
RN can approve, return for correction, or request changes
Once approved, visit is locked and counts toward billing

19.4 HHA Supervisory Visit (Detailed)

Understanding HHA Supervisory Visits

HHA Supervisory Visits are regulatory-required visits where an RN or LPN evaluates the HHA's performance and competency. These are NOT the same as regular HHA visits - they're oversight visits.

Regulatory Requirement

Medicare Requires:

First Supervisory Visit: Within first 2 weeks of patient admission
Ongoing Supervisory Visits: At least once every 2 weeks while HHA services continue
Annual On-Site Supervisory Visit: At least once per year, conducted in person at patient's home

Who Conducts: RN or LPN (depending on state regulations)

Purpose:

Ensure HHA is following the care plan
Assess HHA competency in required skills
Evaluate HHA's interaction with patient/family
Review and update care plan if needed

HHA Supervisory Visit Sections

1. Supervision Details

Select HHA(s) Being Supervised:

Dropdown list of all HHAs assigned to the agency
Can select multiple HHAs if supervising more than one during the visit
System may auto-populate based on who's been visiting the patient

Why Multiple HHAs?: If the patient has multiple HHAs rotating visits, you might supervise more than one during a single supervisory visit.

2. Visit Information

Aide Present: Yes or No (Was the HHA present during the supervisory visit?)
- Yes: RN observed HHA working with patient (preferred for annual visit)
- No: RN visited without HHA present (common for routine checks)
Visit Date: Date of the supervisory visit
Associated Mileage: Travel distance
Annual On-Site Supervisory Visit Date: If this is the annual in-person visit, enter the date

Note on "Aide Present":

Most routine supervisory visits are conducted WITHOUT the HHA present
The annual visit MUST be conducted WITH the HHA present (observed performing tasks)
If "No," RN evaluates based on patient/family feedback and documentation review

3. Competency Evaluation

This section assesses the HHA's skills across 10 competency areas:

Competency Areas:

Personal Care (Bathing, Grooming, Dressing)
Mobility Assistance (Transferring, Ambulation)
Medication Reminders
Vital Signs Measurement
Wound Care
Nutrition and Meal Preparation
Home Safety
Infection Control
Documentation
Communication with Patient/Family

Rating Options (for each area):

Satisfactory: HHA demonstrates competency
Needs Improvement: HHA needs additional training or supervision
N/A (Not Applicable): Skill not required for this patient's care plan

How to Rate:

If HHA was present: RN observes directly and rates based on performance
If HHA was not present: RN rates based on:
- Patient/family feedback
- Review of HHA's documentation
- Observation of patient's condition and environment

4. Performance Criteria

This section uses a 9-item checklist to evaluate the HHA's overall performance:

Checklist Items (Yes/No for each):

Employee follows and implements the care plan.
Employee maintains and implements Standard Precaution per agency policy.
Employee is prompt, stays required length of time and is reliable.
Employee appears competent in the delivery of service.
Employee performs tasks as requested by the client within job description.
Employee relates well with the client/family.
Employee adheres to the dress code.
Employee reports complications and problems to case manager/supervisor.
Employee is caring and sympathetic to the client's needs.

Answering:

Select Yes if the criterion is met
Select No if the criterion is NOT met
Leave blank if unable to assess

If "No" Answers: RN should address issues in the Supervisory Narrative and provide feedback/training to the HHA.

5. Plan of Supervision

This section uses a 3-question checklist to assess the care plan and service needs:

Questions (Yes/No for each):

Is the agency admitting folder readily available?
Does the client have a continued need for services?
Has the employee's care plan been updated as required?

Purpose:

Ensures administrative documentation is complete and accessible
Confirms patient still needs HHA services
Verifies care plan is current and reflects patient's actual needs

6. Supervisory Narrative

Free-text field for the RN/LPN to document:

Summary of Visit: What was observed or discussed
HHA Performance: Detailed notes on competency and performance
Patient/Family Feedback: What patient or family said about the HHA
Care Plan Review: Any changes needed to the care plan
Issues Identified: Any concerns or areas needing improvement
Follow-Up Actions: What will be done (e.g., retrain HHA on infection control)

Example Narrative:

Conducted supervisory visit with patient and family. HHA was not present. 
Patient reports HHA arrives on time, stays full visit, and is very kind. 
Home is clean and well-maintained. Patient's personal care needs are being 
met - patient is clean, hair brushed, nails trimmed. Patient's daughter 
states HHA communicates well and follows instructions. Care plan was reviewed 
with family - no changes needed at this time. Patient continues to need 
assistance with bathing, dressing, and light housekeeping. Overall, HHA 
performance is satisfactory. Will continue biweekly supervisory visits.

Completing the HHA Supervisory Visit

Fill Out All Sections:
- Select HHA(s) being supervised
- Enter visit information
- Rate all competency areas
- Complete performance checklist
- Answer plan of supervision questions
- Write supervisory narrative
Save and Review:
- Click "Save Document" to save progress
- Click "REVIEW" to double-check entries
Complete Visit:
- Click "COMPLETE VISIT"
- Enter password to sign
- Visit is submitted for QA review (if required by agency)

Integration with HHA Care Plan

During the supervisory visit, the RN can:

View the Active HHA Care Plan: Button available to open the care plan PDF
Update the Care Plan: If needed, RN can open the care plan editor and make changes
Create New Care Plan: If no care plan exists, RN can create one

This integration ensures the care plan stays current based on supervisory observations.

19.5 Common Workflow for All Visit Forms

While each visit form is unique to its discipline, they all follow a similar workflow:

1. Opening the Visit

Navigate to My Day or My Schedules
Find the scheduled visit
Click to open the visit form

2. Documenting the Visit

Fill out visit information (date, times, mileage)
Complete discipline-specific assessments or tasks
Record vital signs (if applicable)
Write clinical narrative
Save progress frequently

3. Reviewing the Visit

Click "REVIEW" button
Form becomes read-only
Verify all information is accurate
Click "CANCEL REVIEW" to edit if needed

4. Completing the Visit

Click "COMPLETE VISIT"
Enter password in signature modal
Confirm completion
Visit is submitted to QA Center

5. QA Review (If Required)

RN or QA reviewer opens the visit from QA Center
Reviews for completeness, accuracy, clinical appropriateness
Can approve, return for correction, or add comments
Once approved, visit is locked

19.6 Best Practices for Visit Documentation

For All Clinicians

Document Timely: Complete visits within 24 hours while details are fresh
Be Specific: Use objective, measurable terms (e.g., "Wound measures 3cm x 2cm" vs. "wound looks better")
Include Patient Response: How did patient respond to interventions?
Note Changes: Document any changes in condition, new symptoms, or concerns
Communicate: Note any calls or communications with physician, family, or team members

For HHAs

Check Care Plan First: Always review the active care plan before starting the visit
Complete All Tasks: Mark status for every task - don't leave any blank
Explain "Not Done" or "Refused": If task wasn't completed, explain why in narrative
Report Issues Immediately: Don't wait - call RN if patient has concerning symptoms
Be Professional: Remember your documentation may be read by patient, family, auditors, or attorneys

For RN/LPN Supervisors

Conduct Visits On Schedule: Don't miss the 2-week supervisory visit requirement
Be Fair and Objective: Rate HHAs based on actual performance, not personal feelings
Provide Feedback: Share competency ratings and performance observations with HHAs
Update Care Plans: Use supervisory visits as an opportunity to review and update care plans
Document Follow-Up: If issues are identified, document what actions will be taken

19.7 Troubleshooting

Problem: Cannot Open HHA Visit - "No Active Care Plan"

Cause: No active HHA Care Plan exists for the patient's care order.

Solution:

Navigate to the patient's OASIS assessment (SOC, ROC, or Recert)
Click "Create HHA Care Plan"
Add at least 5 tasks
Save & Activate the care plan
Return to the HHA visit - form should now load tasks

Problem: Cannot Complete HHA Visit - Button is Disabled

Cause: One of these required conditions is not met:

No active HHA Care Plan exists
Clinical document hasn't been saved yet
Required fields are not completed

Solution:

Check for "No active HHA Care Plan" message - create care plan if needed
Click "Save Document" first before attempting to complete
Review form for empty required fields (red asterisks or error messages)

Problem: Tasks Aren't Loading in HHA Visit

Cause:

Care plan exists but has no tasks
Care plan is in "Draft" status (not activated)
Connection error when fetching care plan

Solution:

Verify care plan is "Active" (check Care Order Documents tab)
Open care plan and ensure it has at least 5 tasks
If care plan is "Draft," it needs RN approval
Refresh the page and try again

Problem: HHA Supervisory Visit - Can't Find HHA in Dropdown

Cause:

HHA user doesn't exist in the system
HHA is not assigned to your branch
HHA account is inactive

Solution:

Go to Settings → User Management
Search for the HHA
Verify they have "HHA" role
Check they're assigned to the correct branch
Ensure their account status is "Active"

19.8 Integration with Other Features

QA Review

All visit forms integrate with the QA Review workflow:

Pending Review: After completion, visits appear in QA Center
Soft Alerts: System checks for common documentation issues
Hard Errors: System blocks approval if critical fields are missing
Return for Correction: QA can send visits back to clinician for edits
Approval: Once approved, visit is locked and counts toward billing

Billing

Completed and approved visits trigger billing:

PDGM Grouping: SN/PT/OT/SLP visits contribute to PDGM scoring
HHA Visit Units: Each HHA visit counts as 1 unit for billing purposes
Mileage Tracking: Travel miles are used for reimbursement calculations
Visit Frequency: System tracks if visits match authorized frequency

Medication Management

Some visit forms (SN, LPN, HHA) include medication documentation:

Medication Reconciliation: Update patient's medication list during visit
Medication Profile: Can view/edit patient medications from within visit form
Medication Snapshots: When visit is approved, medication list is captured

Wound Care

SN and LPN visit forms integrate with wound documentation:

Wound Worksheet: Can open patient's wound worksheet from visit form
Wound Care Note: Dedicated form for wound care visits
Photo Upload: Document wound photos directly in visit form