Home Health Missed Visit

P.T. CENTRAL, L.L.C.

HOME HEALTH MISSED VISIT

REPORTING FORM

Agency: _________________ Patient Name: __________________________

MR#: __________________________

The identified patient visit was not made as scheduled for:

_____________ _____________ _____________

Date Day Time

Service: □ PT □ PTA □ OT □ COTA

Due to: □ Unscheduled MD Appointment

□ No one available to answer the door

□ Visit Refused (reason) ____________________________________

□ Other ______________________________________________

Staff follow-up:

□ RN/PCC Notified _____________________

Person

□ Nurse to notify doctor ________________________________________________

Doctor’s Name

□ Unable to reschedule due to: ________________________________

□ Frequency of visits will be met. □ Frequency of visits will not be met.

Additional follow-up needed: _______________________________________________

________________________________________________________________

_______________________ ______________________ ________________

Therapist’s Signature Printed Name Missed visit date