COHS - Encounter Form

Client ID:

Client Name:

DOB:

Date:

Open the calendar popup.

Time Start:

Time End:

Total Miles:

Nurse Home ID:

Home Nurse Visitor Names:

Encounter:

Completed

Attempted

Client Cancelled Visit

Nurse Home Visitor Cancelled

OUTCOME

Encounter Reason:

Deliver Program Content

Client Care Coordination

Efforts to Locate Client

Other

Encounter Method:

In Person

Email

Text

Telephone

Video Conference

Other

If Method Not in Person, indicate Reason:

Client Low Risk Status

Client Busy

Hard to Locate for Home Visits

Weather Conditions

Unsafe Client Neighborhood

Unsafe Client Home

Client Preference/request

Nurse Preference/request

Other

If Client Preference, Specify:

If Nurse Preference, Specify:

If Other, Specify:

Encounter Location:

Client's Home

School

Public/Private Agency

Family/Friends house

Employment

Doctor/Clinic

Other

Encounter Participants:

Client

Child

Clients' Mother

Father of Child

Friend

Doctor/Clinic

Current Husband/Partner

Other Family Member

NFP Supervisor

Child Welfare Services

School

2nd NFP Professional

Interpreter

Other Professional

Other Service Provider

Employer

Other

Participant's Engaged in Visit

Involvement ( rate 1 = low to 5 = high)

Client:

Client Mother:

Husband/Partner/FOC:

Conflict With Material

Client:

Client's Mother:

Husband/Partner/FOC:

Understanding Of Material

Client:

Client's Mother:

Husband/Partner/FOC:

PERCENT OF TIME SPENT ON EACH PROGRAM AREA(in %)

My Health(Personal Health, Health Maintenance Practices, Nutrition and Exercise, Substance Use, Mental Health:

My Home (Environmental Health - Home, Work, School, and Neighborhood):

My Life (Life Course - Family Planning, Education and Livelihood:

My Child / Taking Care of My Child ( Maternal Role - Mothering Roles, Physical Care, Behavioral and Emotional Care of Child:

My Family & Friends ( Personal Network Relationships, Assistance with Childcare:

Do You Have Any Concerns regarding your child's development, behavior or learning?

Yes. No

Not Indicated at the visit

N/A (still pregnant)

Since our last visit, have you had continuous health insurance coverage?

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Child Screened For Needed Services? If Need Complete Referrals to Services Form

Yes

No

No Referral Needed

Did Client/Child user Healthcare services (ex ER visits, well child visits)? Please complete Healthcare Services from if used.

select