Home Health Training
Admin
12.6 Coordination & Supervision

60-Day Summaries and Case Conference Notes

What to gather before you write one, the agency's template, and the sentence that decides whether the insurer keeps paying.

Nursing Updated Sep 18, 2026

The 60-day summary is where the case for continuing gets made. Write it badly and the visits stop, whatever the patient needs.

Gather this first

All of it lives in Episode Manager → Tools:

  • Vital signs report — write down the high and low for comparison by the PCP
  • Falls — found under Communications
  • Medication changes
  • Hospitalizations — transfers or ER visits you know about

Then chart why skilled nursing needs to continue seeing this patient — that sentence is what the insurer reads.

See Skilled Need — The Coverage Test for what makes that reasoning hold up.

The template

Fill each blank from the patient in front of you, not from the last summary.

Patient is a ___-year-old male / female who lives ___ (with family / alone), and has ___ (frequency) assistance from ___ (family, neighbour, etc.) for IADLs.

SN seeing patient ___ times a week for ___. (Document the location of wounds, and whether they have improved or are not healing.)

Patient unable to manage ___ (medications, dressing change, wraps, etc.) due to ___, and has no willing or able caregiver to assist.

It is a taxing effort to leave home due to ___.

History of ___ (medical history). AOx**___**, with ___ forgetfulness. Uses ___ (device) to ambulate / get around. Gait is steady / unsteady and patient is able / unable to navigate uneven terrain safely unassisted.

___ (Foley, PICC) discontinued on cert.

Patient with / without antibiotic use this cert for ___ (ABX reason) that has / has not resolved.

Patient with ___ falls this cert — ___ non-injury and ___ injury falls.

Patient with ___ hospitalizations.

SN to continue seeing patient ___ times a week for ___ (primary focus).

Making it count

The template gives you the structure. These are what make it persuasive:

  • The homebound sentence has to be specific. "It is a taxing effort to leave home due to ___" is the single most important blank on the form. Fill it with observed effort, not a diagnosis — see Homebound Status — What Actually Qualifies.
  • "No willing or able caregiver to assist" is doing heavy lifting for skilled need. If there is a caregiver, say what they cannot safely do and why.
  • Wounds: location, and whether they have improved or are not healing. "Wound care ongoing" says nothing.
  • Falls and hospitalizations are the numbers that justify frequency. Get them from Communications rather than memory.
  • The final sentence — frequency and primary focus — must match what is actually plotted. See Plotting Visits.

What a reviewer is checking

Read your finished summary and ask:

  • Can someone tell why this patient is still on service from this paragraph alone?
  • Does the homebound reasoning match the functional description in the same paragraph?
  • Do the numbers — falls, hospitalizations, frequency — match the rest of the chart?
  • Is the primary focus something that is still in progress, rather than something finished?
  • If every goal were met tomorrow, would this patient be ready for discharge?

If the honest answer to the first question is "because we have been", that is a discharge conversation, not a summary. See Recertification.