MD Vitacare Solutions | Home Health Nurse Note

CMS 2026 Compliant · OASIS‑E1 Ready

Patient Information

Required

Full Name

Patient ID / MRN

Date of Birth

Gender

Home Address

Visit Details & Face‑to‑Face Encounter

CMS Required

Visit Date

Start Time

End Time

Visit Type

Physician Face‑to‑Face Encounter (CMS requirement)

Date of Encounter

Provider Name / NPI

Vital Signs

Measured

BP (mmHg)

HR (bpm)

RR (/min)

Temp (°F)

SpO₂ (%)

Pain (1–10)

Weight (lbs)

Glucose (mg/dL)

Assessment & Findings

Chief Complaint / Reason for Visit

Subjective (Patient's reported symptoms)

Objective (Observations & exam findings)

Clinical Assessment / Impression

Homebound Status Justification

CMS Critical

Medicare requires that the patient be homebound. Document specific functional limitations and/or medical restrictions that make leaving home a considerable and taxing effort.

Requires assistance of another person to leave home?

Yes No

Requires supportive device (cane, walker, etc.)?

Yes No

Describe specific limitations, restrictions, or structural barriers

OASIS‑E1 Data Link

All‑Payer

Functional Status (OASIS M1800 series)

Living Situation (OASIS M1100)

Relevant OASIS Findings (e.g., cognition, pain, skin, medications)

Medications & Treatments

Medications Administered / Given

Treatments / Procedures Performed

Patient & Caregiver Education

Education Provided

Education understood by: Patient Caregiver Family Member

Plan of Care

Next Steps / Plan

Next Scheduled Visit

Visit Frequency

Care Team Communication

Coordination

Communication with Provider / Team

Nurse Signature

Nurse Name (Printed)

Title / Credentials

Digital Signature

By signing, you attest that the information is accurate and complete.

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