Documentation and Data Collection

Documentation of home visits is to be done in a timely, objective, and accurate manner, and must be maintained in a secure file location. Each agency should have policies and procedures in writing that address documentation and maintenance of the client records.

Appropriate Record Maintenance

For information on information management and patient-integrated records, consult the American Medical Association’s Code of Medical Ethics Opinion 3.3.1.

Timing and Professionalism

Thorough and objective documentation of a home visit should occur within 24 hours following the visit and will be a part of the permanent client record. Home Visitors must be professional and objective in their writing, keeping in mind that records could be subpoenaed in court. Documentation needs to focus on what is seen and heard, not assumed conclusions of the home visitor.

Specific Visit Data

Data obtained from Home Visitors assists MCH grantees in demonstrating progress being made toward meeting the National Performance Measures (NPM) and State Performance Measures (SPM) for the Title V MCH program.

Data collected for home visiting services includes, but is not limited to, the following:

  • Where services were provided (setting)
  • What education was provided
  • What referrals were provided and completed
  • Number of mothers served prenatal and postnatal
  • Number of children and other family members impacted through visits
  • Number of visits made overall

Grantees must capture all required client demographics and service/encounter data via the web-based shared measurement system, DAISEY (Data Application and Integration Solutions for the Early Years), and this must be entered/submitted no later than the 10th of each month.

Client-level data is captured on the following DAISEY forms:

  • Adult Profile
  • Child Profile (only if infant visit is included in the service)
  • Program Visit Form (Adult or Child)
  • MCH Service Form
  • Referral Form

NOTE: Services provided to the infant or child are not documented as home visiting services. If the infant or child requires services, these should be documented by the professional staff that conducts their assessment and intervention. Visits can be completed by a Home Visitor and professional staff on the same day or at the same visit, as these services are not duplicated and are not provided by the same level of practitioner.