Every question, every section
Walk through the full patient assessment before your first home visit. Every section, every field - so nothing catches you off guard.
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Assessment Sections
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Table of Contents
Visit Info
Captures the basic logistics of the visit - who is present and the patient's household situation. Visit date, patient DOB, and task type are pre-filled from the agency.
Is the caregiver present?
Is there anyone else in the house related to the patient?
Relationship to the patient
Vital Signs
Records the patient's core physiological measurements - temperature, blood pressure, pulse, and respiration. Each measurement includes the method used, ensuring clinical accuracy and reproducibility across visits.
Body temperature (°F)
Method: Oral / Axillary / Rectal / Remote/Forehead
Blood pressure (Systolic/Diastolic)
Method: In the Right Arm / In the Left Arm
Pulse rate (bpm)
Method: Regular / Irregular
Respiration rate (breaths/min)
Method: Regular / Shallow / Labored
Your Narrative Response (for "teaching provided" section)
Medications
Documents every medication the patient currently takes - including vitamins and over-the-counter items. The RN photographs the medication bottles and uses the app to build a complete medication list with name, form, and dosage. An AI-generated narrative and teaching section follows.
Does the patient take any medications? (Including vitamins and over the counter medications)
Medications
Each medication shows: Name, Form (Oral Pill, Oral Liquid, Injectable), and Dosage. "Manage Medications" button to add/edit.
Your Narrative Response (for "teaching provided" section)
Medical History
Captures the patient's full medical history and known conditions in their own words. If the patient was hospitalized in the last 6 months, the reason and post-hospitalization condition are documented here. AI-suggested diagnosis codes follow.
Please describe the patient’s medical history and known conditions. If patient was hospitalized in the last 6 months add reason for hospitalization and condition post hospitalization
Pain
Evaluates whether the patient has experienced pain in the last 3 days - including intensity, characteristics, location, duration, and relief methods. Both verbal reports and non-verbal pain behaviors are documented. AI-suggested diagnosis codes follow.
In the last 3 days, has the patient complained of pain or shown any signs of pain (for example, facial grimacing, guarding, moaning, crying)?
In the last 3 days, what was the highest level of pain the patient experienced?
What are the pain characteristics?
Over the last 3 days, describe how long the patient’s pain usually lasts when it occurs (for example: seconds, minutes, hours, constant).
Where is the pain located?
What relieves the pain? (Medication, Ice, Elevation, other..)
From the patient’s point of view, are the current methods adequately controlling their pain?
Pain Intensity After Intervention (can’t be higher than the original pain level)
In the last 3 days, which of the following non-verbal pain behaviors have been observed? (mark all that apply)
Your Narrative Response (for "teaching provided" section)
Neurological
Screens for cognitive, sensory, and behavioral findings. The RN assesses level of consciousness, orientation, mood/behavior symptoms, and neurological symptoms like tremors, seizures, or paralysis. AI-suggested diagnosis codes and a narrative & teaching review follow.
Level of Consciousness: How would you describe the patient’s level of alertness today?
Orientation: Is the patient currently oriented to person, place, and time?
Does the patient have any mood or behavior findings?
Does the patient experience any neurological symptoms?
Your Narrative Response (for "teaching provided" section)
EENT (Eyes, Ears, Nose, Throat)
Assesses conditions affecting the patient's head, face, eyes, ears, and mouth/throat. Each area is screened independently with multi-select symptom checklists. AI-suggested diagnosis codes and a narrative & teaching review follow.
Does the patient have any head or face symptoms?
Does the patient have any eye or vision conditions?
Does the patient have any hearing difficulties, conditions, or use hearing devices?
Does the patient experience any mouth, throat, or speech symptoms?
Your Narrative Response (for "teaching provided" section)
Cardiopulmonary
The most detailed body-system section. Evaluates heart and circulation symptoms, edema, cardiovascular devices, breathing and lung symptoms, respiratory support devices, oxygen delivery details, and lung sounds. Deep conditional logic branches based on oxygen use. AI-suggested diagnosis codes and a narrative & teaching review follow.
Does the patient experience any heart or circulation symptoms?
Edema Location
Edema Grade
Does the patient currently use any cardiovascular devices? (select all that apply)
Does the patient experience any breathing or lung symptoms?
Does the patient use any respiratory support devices?
How is oxygen being delivered?
Specify oxygen flow rate (LPM)
Specify oxygen frequency
PRN oxygen — how often as needed?
Intermittent oxygen schedule
What are the patient’s lung sounds on assessment?
Your Narrative Response (for "teaching provided" section)
Musculoskeletal
Assesses muscle, bone, and joint symptoms including numbness, weakness, gait abnormalities, amputations, coordination problems, stiffness, deformities, and limited range of motion. AI-suggested diagnosis codes and a narrative & teaching review follow.
Does the patient experience any muscle, bone, or joint symptoms?
Your Narrative Response (for "teaching provided" section)
GI/GU/Reproductive
Covers the gastrointestinal, genitourinary, and reproductive systems. Documents digestive symptoms, ostomy status, bladder/urinary symptoms, and gender-specific reproductive conditions. AI-suggested diagnosis codes and a narrative & teaching review follow.
Does the patient experience any stomach, bowel, or digestive symptoms?
Does the patient have an ostomy?
Ostomy (type & location)
Does the patient experience any bladder or urinary symptoms?
Patient Gender
Does the patient have any female reproductive conditions, breast problems, or history? (select all that apply)
Does the patient have any male reproductive conditions, symptoms, or history? (select all that apply)
Your Narrative Response (for "teaching provided" section)
Integumentary / Hematopoietic / Endocrine
Covers skin conditions and wounds (with detailed wound staging), blood-related disorders, and hormone/gland conditions. When diabetes is detected, a dedicated diabetic education checklist and blood glucose reading are required. AI-suggested diagnosis codes and a narrative & teaching review follow.
Does the patient currently have any skin symptoms or skin problems? (select all that apply)
Wound Location
Wound Size
Wound Appearance
Wound Stage
Does the patient have any blood-related conditions or problems? (select all that apply)
Does the patient have any hormone or gland-related conditions? (select all that apply)
Which diabetic education was provided? (select all that apply)
Blood Glucose Level
Skin Color on exam
Your Narrative Response (for "teaching provided" section)
Allergies and Nutrition
Assesses the patient's appetite, weight trends, fluid restrictions, eating independence, special medical diets, nutrient restrictions, food texture needs, and all allergy types - medication, food, and environmental. A narrative & teaching review follows.
Select the most accurate option for the patient’s appetite over the last 3 days:
Current weight (lbs)
Compared with their usual weight over the past few months, the patient’s weight is:
Is the patient on a prescribed fluid restriction?
Fluid Restriction Amount
Over the last 3 days, how has the patient been eating and drinking?
Does the patient follow any special medical diet? (select all that apply)
Does the patient have specific nutrient restrictions? (select all that apply – only if NOT covered by medical diet above)
Does the patient need any special food textures because of chewing or swallowing problems?
Does the patient have any medication allergies? (e.g., Penicillin, Sulfa, Cephalosporins, Aspirin, NSAIDs, Opioids)
Does the patient have any food allergies? (e.g., Shellfish, Milk, Peanuts, Tree Nuts, Fish)
Does the patient have any substance or environmental allergies? (e.g., Latex, Pollen, Dust Mites, Mold, Pet Dander, Insect Stings)
Your Narrative Response (for "teaching provided" section)
Environment and Safety
Documents the patient's living arrangement and screens for environmental and safety hazards in the home — from structural issues and fire safety to unsecured rugs and medication storage. A narrative & teaching review follows.
What is the patient’s living arrangement?
Are there any environmental or safety hazards in the patient’s home?
Your Narrative Response (for "teaching provided" section)
DME and Supplies
Records all durable medical equipment and supplies the patient uses at home — mobility equipment, bathroom safety devices, bedroom/positioning equipment, and medical supplies like glucometer strips or wound care materials. A narrative & teaching review follows.
Does the patient currently use any mobility equipment to get around? (select all that apply)
Does the patient have or use any bathroom safety equipment at home? (select all that apply)
Does the patient have or use any bedroom or positioning equipment? (select all that apply)
Does the patient regularly use any medical supplies at home? (select all that apply)
Your Narrative Response (for "teaching provided" section)
Emergency and Advance Directives
Documents the patient's emergency contact, physician information, emergency preparedness checklist, and advance directive status (Healthcare Proxy, DNR). Teaching provided is documented at the end.
Emergency Contact - Name, Address, Phone
Contact person outside of the home - includes name, address, and phone number
Patient Physician
Search/add physician
Emergency Plan Discussed?
Emergency Preparedness
Advance Directives
Teaching Provided
Immunization
Tracks the patient's immunization history across five vaccine categories — Influenza, Pneumonia, COVID-19, Tetanus, and Hepatitis B — plus any other immunizations. Documents refusal status and whether educational information was provided. A narrative & teaching review follows.
Influenza immunization
If yes, enter date of immunization
Pneumonia immunization
If yes, enter date of immunization
COVID-19 immunization
If yes, enter date of immunization
Tetanus immunization
If yes, enter date of immunization
Hepatitis B immunization
If yes, enter date of immunization
Other immunization
If yes, enter name and date of immunization
Did the patient refuse immunizations?
Educational info provided?
Your Narrative Response (for "teaching provided" section)
Diagnosis Information
The comprehensive diagnosis code review. The AI generates suggested ICD-10 codes based on all findings from the assessment. The RN reviews, adds, or removes codes and categorizes each as Principal (primary) or Other (secondary) before approving for submission.
Diagnosis Codes
AI-generated suggestions via "Generate with AI" button. Manual entry via "Add Code" button. Codes categorized as PRINCIPAL (primary) or OTHER (secondary).
I have reviewed the diagnosis codes and approve them for submission.
Must be checked to proceed
Fall Risk
Screens for fall history in the past 3 months. The narrative response here feeds directly into the teaching provided section of the final assessment. A narrative & teaching review follows.
Did the patient have a history of falls in past 3 months?
Your Narrative Response
This text will be included in the teaching provided section
Summary
The final section where the patient and RN sign off on the completed assessment. Once both signatures are captured, the assessment is ready for submission.
Patient Signature
RN Signature
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