The Routine Follow-Up Visit
The visit you will do most often — what it has to contain, how to keep it from becoming a social call, and how to end it well.
Most of your working life is this visit. It has no OASIS attached and no formal deadline beyond the note, which is exactly why it drifts — into a pleasant chat, a set of vitals, and a note that could have been written about anybody.
Every follow-up visit has to stand on its own for skilled need and homebound status. See What Every Visit Note Must Prove.
Before you knock
Two minutes in the car:
- What is the plan of care asking for today?
- What did the last clinician say in Plans for Next Visit?
- Any new orders, lab results, or hospital contacts since?
- What is my skill on this visit — assessment, education, or hands-on care?
Walking in without an answer to the last one is how a visit becomes a social call.
In the home
Every visit, without exception
- Vital signs and pulse oximetry — every skilled discipline, every visit
- Focused assessment for the condition driving the episode
- Homebound status — observed today, matched to what you write
- Skilled intervention tied to an order on the plan of care
- Stoma appearance, if an ostomy is present
The clinical work
Whatever the plan of care orders: the dressing change, the teaching, the exercise progression, the medication review. Do what is ordered, and only what is ordered — see Verbal Orders and Clarifications.
Teaching has to move
Teaching is skilled while it is still teaching. Each visit should show progression:
- What you taught today, specifically
- Why it is needed now
- How the patient responded — teach-back, return demonstration, what they got wrong
- What is left
The same teaching, delivered identically, four visits running with no change in understanding is the pattern reviewers look for.
Look for what nobody asked you to look for
You are the only clinician who sees this house. Notice:
- Pill bottles that have not moved since last week
- New bruising
- Less food in the kitchen
- A caregiver who looks exhausted
- A device that has been put in a cupboard
Some of the most useful things you will ever document were not on the plan of care.
Before you leave
- Plans for next visit written specifically — "re-educate on insulin, patient to return demonstrate", not "continue plan of care"
- The patient knows when you are coming back and who is coming
- The patient knows what would make them call
- Anything needing the physician has been called in, and the call is documented with the time
- Anything needing another discipline has been passed on
- The note is written — in the home or in the car outside it
Discharge planning, every visit
Every follow-up visit should move the patient one step closer to not needing us. Ask:
- What has to be true before this patient can be discharged?
- Are we closer to it than last week?
- If not, what am I changing?
If the honest answer three visits running is "no closer", the episode needs a different plan or a discharge conversation.
LUPA — worth knowing
If the number of visits in a 30-day payment period falls below a threshold set for that patient's case-mix group, the period is paid per-visit instead of as an episode. The thresholds vary by group.
This is not a reason to make a visit that is not needed — that is fraud. It is a reason to make sure visits that are clinically needed and ordered actually happen, and to raise it early when a patient keeps cancelling. Talk to your Field Supervisor rather than working it out alone.
Where follow-up visits go wrong
- The note could describe any patient. If you could swap the name and nobody would notice, there is no assessment in it.
- Homebound status contradicts the assessment in the same note.
- An intervention performed without an order.
- "Continue plan of care" as the plan for next visit — it tells the next clinician nothing.
- Charting hours later. Detail decays fast, and the notes pile into weekends.