Community Health Worker Home Visit Documentation

Captures visit purpose, health education delivered, vitals or screenings completed, barriers identified, referrals made, and follow-up needed at a household visit. Designed for CHWs to meet Medicaid managed care documentation requirements and grant reporting standards.

Visit Logistics

• Community Health Worker Name
• CHW Employee / Credential ID
  Enter your organization-assigned ID or state CHW certification number where applicable.
• Date of Visit
• Visit Start Time
• Visit End Time
• Visit Modality
  Select the primary mode of contact for this encounter.
• Visit Location Address
  Required for in-person home visits. Omit if telehealth or community site.
• Program / Grant Name
  Select the funding source or program under which this visit is being documented.

Participant Information

• Participant Record / MRN
  Use your organization's assigned participant ID or medical record number. Do NOT enter Social Security numbers.
• Participant Full Name
• Date of Birth
  Required for Medicaid encounter matching.
• Participant's Preferred Language
• Was an interpreter used during this visit?
• Number of Household Members Present During Visit
  Include the participant. Useful for household-level interventions and grant reporting.
• Participant Consent for Visit and Documentation Confirmed
  Confirm that the participant has been informed of the purpose of this visit and consents to documentation in their care record per your organization's HIPAA Notice of Privacy Practices.

Visit Purpose and Goals

• Primary Purpose of This Visit
• If 'Other', describe the visit purpose
• Care Plan Goals Addressed During This Visit
  Select all goals from the participant's active care plan that were discussed or worked on.
• Narrative Summary of Visit Goals and Context

Health Education Delivered

• Health Education Topics Covered
  Select all topics addressed. At least one topic is required if visit purpose includes health education.
• If 'Other', describe the education topic
• Education Delivery Format(s) Used
• Participant's Demonstrated Understanding (Teach-Back Result)
  Document the result of teach-back or comprehension check per health literacy best practices.
• Education Notes

Vitals and Screenings

• Were any vitals or screenings performed during this visit?
• Blood Pressure – Systolic (mmHg)
  Enter systolic reading. Flag readings ≥ 180 for immediate clinical escalation.
• Blood Pressure – Diastolic (mmHg)
  Enter diastolic reading. Flag readings ≥ 120 for immediate clinical escalation.
• Blood Glucose (mg/dL)
  Point-of-care fingerstick result. Flag readings < 70 or > 400 for clinical escalation.
• Weight (lbs)
• Validated Screening Tools Administered
  Select all standardized screening instruments used during this visit.
• Were any abnormal or concerning findings identified?
• Describe Abnormal Findings and Actions Taken

Social Needs and Barriers

• Social Needs Identified During This Visit
  Select all unmet social needs identified. Select 'None identified' if no needs were disclosed.
• Barriers to Accessing Health Care Identified
• Is there an immediate safety concern for this participant or household?
  Mandatory reporter obligations apply. If yes, follow your organization's safety protocol immediately.
• Social Needs and Barriers – Additional Notes

Referrals and Resources Provided

• Referrals Made During This Visit
  Select all referrals initiated. Select 'No referrals made' if none were needed.
• If 'Other', describe the referral
• Was a warm handoff completed for any referral?
  A warm handoff means you directly connected the participant to the receiving provider or service (e.g., called together, scheduled appointment in real time).
• Materials or Resources Left with Participant

Follow-Up Plan and CHW Attestation

• Is Follow-Up Required After This Visit?
• Planned Follow-Up Date
• Follow-Up Contact Type
• Follow-Up Goals and Action Items
• Does Your Supervisor Need to Be Notified About This Visit?
  Select 'Yes' for urgent findings, mandatory reporting situations, or cases requiring clinical escalation.
• Overall Visit Notes / SOAP or Narrative Summary
• CHW Attestation
  I certify that the information recorded in this form is accurate and complete to the best of my knowledge, that this visit was conducted as described, and that documentation complies with my organization's policies and applicable Medicaid and grant documentation requirements.
• CHW Electronic Signature
  Sign to finalize and submit this visit record.