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Run: Community Health Worker Home Visit Documentation

Document each community health worker home visit in one place, including visit purpose, education delivered, screenings, barriers, referrals, and follow-up. ...

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Visit Logistics

Community Health Worker Name (required)

CHW Employee / Credential ID (required)

Enter your organization-assigned ID or state CHW certification number where applicable.

Date of Visit (required)

Visit Start Time (required)

Visit End Time (required)

Visit Modality (required)

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 (required)

Select the funding source or program under which this visit is being documented.

Participant Information

Participant Record / MRN (required)

Use your organization's assigned participant ID or medical record number. Do NOT enter Social Security numbers.

Participant Full Name (required)

Date of Birth (required)

Required for Medicaid encounter matching.

Participant's Preferred Language (required)

Was an interpreter used during this visit? (required)

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 (required)

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.

Yes No N/A

Visit Purpose and Goals

Primary Purpose of This Visit (required)

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 (required)

Health Education Delivered

Health Education Topics Covered (required)

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 (required)

Participant's Demonstrated Understanding (Teach-Back Result) (required)

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? (required)

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? (required)

Describe Abnormal Findings and Actions Taken

Social Needs and Barriers

Social Needs Identified During This Visit (required)

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? (required)

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 (required)

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? (required)

Planned Follow-Up Date

Follow-Up Contact Type

Follow-Up Goals and Action Items

Does Your Supervisor Need to Be Notified About This Visit? (required)

Select 'Yes' for urgent findings, mandatory reporting situations, or cases requiring clinical escalation.

Overall Visit Notes / SOAP or Narrative Summary (required)

CHW Attestation (required)

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.

Yes No N/A

CHW Electronic Signature (required)

Sign to finalize and submit this visit record.

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