Components of the Visit Notes

Other Forms Used: Each visit note consists of a space to indicate if other forms were used to document on during the visit such as a wound flow sheet. The system discourages double documentation.

Homebound Status: Cues are provided to document homebound status on a regular basis. A more detailed description is to be documented in the appropriate care element and documented in the "comment" section.

Care Elements: Each visit note is set up with the care elements along the left hand side. These are categories of interventions that are typically performed during the visit.

Interventions: Interventions that are typically performed on specific visits are presented on each visit note. The visit-specific interventions and outcomes progress in level of difficulty from the beginning to the end of the pathway. Each visit note is unique (nursing). The clinician places a "check" on the line to the right of each intervention that is completed OR documents a variance code if the intervention is not completed. Variance codes are mainly patient-centered reasons used to explain why interventions are not done or why outcomes are not met.

Comments: Assessment findings and other noteworthy patient information are documented in the comment section.

Outcomes: The patient outcomes are documented as met or not met with a variance code.

Plan: This section is to document the "plan for next visit." The plan is usually presented (the next visit note). Additional interventions and assessments that are not included on the next visit notes may be indicated here (usually related to a secondary condition).