Home Health SOAP Notes: Complete Guide with Examples

Updated January 2026

Home health documentation requires unique considerations that differ from facility-based care. This guide covers SOAP note structure for home health nurses, therapists, and aides, with emphasis on homebound status documentation, safety assessments, and Medicare compliance.

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Subjective Section (S)

The Subjective section in home health captures the patient's self-reported status, symptoms, and concerns in their home environment. This includes caregiver input and observations about the patient's daily function.

Subjective Section Components

1. Chief Complaint/Reason for Visit:

   • The primary concern or reason for today's home visit
   • Example: "Patient reports increased shortness of breath with activity over the past 3 days."

2. Patient-Reported Symptoms:

   • Pain levels, changes in condition, new symptoms
   • Medication side effects or concerns
   • Example: "Patient states pain at wound site has decreased from 6/10 to 3/10 since last visit."

3. Functional Status Changes:

   • Self-reported ability to perform ADLs and IADLs
   • Changes since last visit
   • Example: "Patient reports needing more assistance with bathing; unable to stand in shower as of yesterday."

4. Medication Adherence:

   • Patient's report of medication compliance
   • Any missed doses or concerns
   • Example: "Patient states taking all medications as prescribed. Denies confusion about medication schedule."

5. Caregiver Report:

   • Information provided by family members or caregivers
   • Observations about patient function between visits
   • Example: "Daughter reports patient has been eating well but seems more confused in the evenings."

6. Home/Environmental Concerns:

   • Patient or caregiver concerns about the home environment
   • Equipment needs or issues
   • Example: "Patient states hospital bed is uncomfortable; requests assessment for pressure-relieving mattress."

Example of a Subjective Section for Home Health

Objective Section (O)

The Objective section documents measurable findings from the home visit assessment, including vital signs, physical examination, wound assessment, home safety observations, and functional status evaluation.

Objective Section Components

1. Vital Signs:

   • Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation
   • Weight if applicable (compare to baseline)
   • Example: "BP 138/82, HR 74, RR 16, Temp 98.2°F, SpO2 96% on RA, Weight 165 lbs (unchanged from admission)"

2. Physical Assessment:

   • System-specific examination based on diagnosis
   • Wound assessment with detailed measurements if applicable
   • Example: "Lungs: Clear to auscultation bilaterally. No peripheral edema. Surgical incision: 12 cm right lateral hip, well-approximated, staples intact x24, no erythema, drainage, or dehiscence."

3. Functional Assessment:

   • ADL performance observed during visit
   • Mobility status with assistive devices
   • Example: "Ambulated 50 feet with rolling walker, standby assist x1, steady gait, maintained hip precautions. Transfers supine to sit: minimal assist x1."

4. Medication Review:

   • Verification of medication compliance and organization
   • Pill count if indicated
   • Example: "Medication reconciliation completed. All medications accounted for in pillbox. Patient correctly identified purpose and dosage of Eliquis."

5. Home Safety Assessment:

   • Environmental hazards identified
   • Safety equipment in place and functioning
   • Example: "Home safety: Hospital bed in living room with side rails, bedside commode in place. Throw rugs removed from pathway per previous recommendation. Grab bar installed in bathroom."

6. Caregiver Assessment:

   • Caregiver presence and involvement observed
   • Demonstrated skills or competency
   • Example: "Daughter demonstrated proper technique for assisting with transfers using gait belt. Verbalized understanding of hip precautions."

Example of an Objective Section for Home Health

Assessment Section (A)

The Assessment section synthesizes findings into clinical judgment about the patient's status, homebound status justification, and progress toward goals.

Assessment Section Components

1. Primary Diagnosis Status:

   • Current status of the primary diagnosis
   • Response to treatment
   • Example: "Right hip ORIF, POD #7, healing appropriately without signs of infection."

2. Homebound Status Justification:

   • Specific reasons patient is homebound per Medicare criteria
   • What makes leaving home a considerable and taxing effort
   • Example: "Patient is homebound due to: recent right hip ORIF requiring assistive device for all ambulation, weight-bearing restrictions, and need for assistance with transfers. Leaving home requires considerable effort and causes significant fatigue."

3. Skilled Care Justification:

   • Why skilled nursing/therapy services are medically necessary
   • Why these services cannot be safely performed by patient/caregiver
   • Example: "Skilled nursing required for: wound assessment and monitoring for post-surgical complications, medication management education, fall prevention instruction, and care coordination."

4. Progress Toward Goals:

   • Status of established care plan goals
   • Goal achievement or modifications needed
   • Example: "Goal: Ambulate 100 feet with walker, minimal assist - progressing. Currently at 50 feet with standby assist. On track to meet goal by discharge."

5. Barriers/Concerns:

   • Issues affecting care or recovery
   • Caregiver concerns or limitations
   • Example: "Barrier: Daughter returning to work limits caregiver availability during daytime hours. Home health aide referral being processed."

Example of an Assessment Section for Home Health

Plan Section (P)

The Plan section outlines the care plan, skilled interventions, patient/caregiver education, and coordination activities.

Plan Section Components

1. Skilled Interventions This Visit:

   • Specific skilled services provided today
   • Example: "Wound care: Cleansed incision with normal saline, applied dry sterile dressing. Performed medication reconciliation. Instructed on fall prevention strategies."

2. Patient/Caregiver Education:

   • Teaching provided and topics covered
   • Patient/caregiver response and understanding
   • Example: "Educated patient and daughter on signs of wound infection (increased redness, warmth, drainage, fever). Return demonstration of proper use of incentive spirometer - patient demonstrated correct technique."

3. Care Coordination:

   • Communication with physicians, other disciplines, or agencies
   • Referrals made
   • Example: "Contacted orthopedic office regarding staple removal - scheduled for POD #14. Coordinated with PT regarding HEP progression. Submitted referral for home health aide services."

4. Next Visit Plan:

   • Frequency and duration of visits
   • Goals for next visit
   • Example: "Continue skilled nursing visits 3x/week for 2 weeks, then reassess. Next visit: Wound assessment, continue education, coordinate staple removal."

5. Physician Notification:

   • Any reportable findings communicated to MD
   • Orders obtained or requested
   • Example: "No reportable findings this visit. Will notify MD if signs of SSI develop or if functional decline noted."

Example of a Plan Section for Home Health

Medicare Documentation Requirements

Home health documentation must meet specific Medicare requirements for reimbursement. Key elements include:

OASIS Alignment

Ensure your SOAP notes support OASIS assessments:

• Functional status should align with OASIS M1800-M1870 (ADL/IADL scores)
• Homebound status documentation supports SOC/ROC
• Skilled need justification supports certification

Homebound Status Criteria

Document at least ONE of the following:

1. Need for assistive device, assistance of another person, or both to leave home
2. Medical condition that restricts ability to leave
3. Medical condition that makes leaving home medically contraindicated

AND document that leaving home requires considerable and taxing effort.

Skilled Care Necessity

Document why services require a skilled professional:

• Assessment and monitoring that requires clinical judgment
• Teaching that requires specialized knowledge
• Procedures that require clinical training
• Care planning that requires professional expertise

AI-Assisted Documentation for Home Health

Mobile AI documentation tools are particularly valuable for home health clinicians who document in various settings without access to desktop computers.

Benefits for Home Health

• Mobile documentation: Create notes during or immediately after home visits
• Reduced travel burden: Complete notes without returning to office
• Consistent structure: Ensure Medicare-compliant documentation
• Time savings: Reduce documentation time by 50-75%

Tips for Using AI with Home Health Documentation

1. Dictate during visits: Record key findings while fresh
2. Include specific measurements: "Wound 4 cm x 2 cm, depth 0.5 cm"
3. State homebound justification: "Patient requires maximum assistance to leave home"
4. Document caregiver involvement: "Daughter demonstrated proper technique for medication administration"
5. Specify skilled interventions: "Performed medication reconciliation and anticoagulation teaching"