Random Visit / Monitoring Form
Visit Information
Location / Service Area:
*
Home, Phone, Email, Video Call, Text/SMS?
Client Name:
*
Date of Visit:
*
-
Month
-
Day
Year
Date
Type of Visit:
*
In-Person Random Visit
Phone Monitoring Visit
Virtual Monitoring Visit
Supervisory Wellness Check
Follow-Up Visit
Wellness and Health Screening
1. Has the client experienced any symptoms within the last 48 hours?
*
Fever or Chills
Cough
Shortness of Breath
Headache
Sore Throat
Congestion or Runny Nose
Nausea or Vomiting
Diarrhea
No Symptoms Reported
2. If symptoms were reported, what is the plan of care or follow-up action?
*
Write N/A if no symptoms reported
Back
Next
Caregiver Presence and Timeliness
3. Is the assigned caregiver present during the visit?
*
Yes
No
Not Applicable
4. Was the caregiver on time for the scheduled shift?
*
Yes
No
Not Applicable
If no, explain:
*
Write N/A if not applicable
Client Safety and Concerns
5. Are there any concerns reported or observed?
*
6. Does the client report feeling safe?
*
Yes
No
Unsure
If concerns are identified, explain:
*
Write N/A if not applicable
Environmental and Home Safety Monitoring
7. Are community/building elevators functioning properly?
*
Yes
No
Not Applicable
Comments:
Back
Next
8. Are smoke detectors operational in the home?
*
Yes
No
Unsure
9. Action plans or follow-up regarding safety concerns:
*
Write N/A if not applicable
Care Plan Changes and Additional Notes
10. Are any care plan updates or additional notes needed?
*
Financial Boundaries and Client Protection
11. Has the client expressed concerns regarding money, borrowing, food requests, SNAP/debit cards, or financial boundaries?
*
No Concerns Reported
Concerns Reported (Explain Below)
*
Write N/A if not applicable
Follow-Up and Escalation
Back
Next
12. Was supervisory leadership notified of concerns?
*
Yes
No
Not Applicable
If yes, document actions taken:
*
Write N/A if not applicable
13. Additional Follow-Up Needed
*
Nursing Follow-Up
Scheduling Follow-Up
Supervisor Review
Safety Follow-Up
Care Plan Review
No Additional Follow-Up Needed
Administrative Documentation
Admin / Staff Signature:
*
Date Completed:
*
-
Month
-
Day
Year
Date
Admin / Staff Name:
*
Documentation Standards Reminder
All Random Visit / Monitoring documentation must remain professional, objective, accurate, respectful, HIPAA-conscious, and fact-based.
Preview PDF
Submit
Should be Empty: