Home Health Missed Visit Form
PCS Documentation for Senior Care/Medicaid Waiver Clients
Client Name
*
Enter the Client's name who's visit was missed.
1. Missed Date
*
/
Month
/
Day
Year
Enter the date of the Missed Visit.
2. Shift Start Time
*
Enter the scheduled start time of the shift.
3. If multiple days, weeks, or a range of days will be missed enter below. Enter the first missed date of the multiple in box 1.
4. Reason
*
Please Select
An employee called out, and backup support was suggested.
An employee had planned time away, and backup support was suggested.
The visit was canceled by the client.
The client was/is hospitalized.
The client canceled due to sickness.
The client is away on vacation.
Holiday observance.
No staff available- encouraged to use backup support.
Delayed Start-client delayed/hospitalization
Delayed Start-assessment scheduling delay
Delayed Start-no staff, backup support suggested
Client Rescheduled for another day
Select the reason for the missed visit.
5. Date Case Management Team Notified
*
/
Month
/
Day
Year
Enter the date the Case Management Team was notified. *Must be within 24 hours or less of the missed visit or sooner.
Notes?
*
6. Admin Name
*
First Name
Last Name
7. Admin Signature
*
8. Date
*
/
Month
/
Day
Year
The date that the Admin is completing this form.
Preview PDF
Submit
Should be Empty: