VisitIQ  ·  Home Health Visit Intelligence  ·  Concept prototype — Sarah Brock, NHA  ·  Fictional patient data throughout
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VisitIQ
HOME HEALTH VISIT INTELLIGENCE
Larimer County HH  ·  Morning Route
MORNING ROUTE  ·  THU JUL 24
4 patients on service today
MR
M. Rivera, RN
VisitIQ
Home Health Visit Intelligence
Clinical data transfers between visits. What the clinician knows doesn't.
Every home health visit, the outgoing clinician knows things about the patient that never make it into the chart — the son who complicates care decisions, the medication the patient is quietly skipping, the fall hazard that appeared since last week. VisitIQ captures that intelligence and surfaces it to the next clinician before they knock on the door.
What gets captured
Clinical Escalation — Dorothy gained 3 lbs. She skipped Lasix again.
Home Environment — New throw rug in Rosa's bathroom. It wasn't there Monday.
Safety Flags — Call James before you arrive. The dog is loose.
What the Chart Won't Say — Rosa says 3/10. Treat her like a 6.
What this prototype demonstrates
Post-visit debrief intelligence surfaced to the next clinician before they walk into the home
AI-generated "Know Before You Knock" briefing from prior visit notes — the things that don't make the chart
Action triggers: MD calls, visit frequency changes, supply orders — surfaced automatically from visit notes
A start of care visit that inherits 22 SNF shifts of intelligence, plus CHF escalation, wound care non-adherence, and pain underreporting
Four patients on service — each showing something different
Start of CareTransferred from SNF5 insights inherited
Mary Johnson78F · Post-ORIF hip · Visit 1 of 12 · 8:00 AM
Discharged from Sunrise SNF this morning after 11 days. Normally Visit 1 is where the clinician knows nothing. Mary arrives with 22 shifts of accumulated intelligence already translated for the home, including the pain pattern that decides whether her therapy works and the help-seeking behavior that predicts her fall risk. This profile shows what a start of care visit looks like when it isn't a blank slate.
Open
UrgentWeight up 3 lbsLasix non-adherence
Dorothy Chen78F · CHF · Visit 4 of 9 · 9:15 AM
Dorothy gained 3 lbs in 48 hours and she's been skipping her Lasix because it disrupts her errands. The outgoing nurse wrote: "She didn't want me to write that down. I wrote it down." This profile shows VisitIQ escalating a clinical risk that the patient is actively trying to minimize.
Open
WatchWound changedSafety: dog
James Whitfield67M · Diabetic wound care · Visit 6 of 12 · 11:30 AM
The wound bed changed since last week. James has been standing on his heel in the garage — he doesn't feel pain because of his neuropathy, which is exactly why it's dangerous. And there's a German Shepherd loose in the home. Call before you knock. This profile shows safety flags and patient education gaps that only clinical observation captures.
Open
On trackPain underreporterInterpreter needed
Rosa Mendez83F · Post-hip replacement PT · Visit 7 of 14 · 2:00 PM
Rosa says 3/10. The last PT documented that she visibly winced during a pivot and said 3/10 anyway. Her granddaughter Marisol softens everything in translation. And there's a new throw rug in the bathroom that wasn't there Monday. This profile shows communication barriers and environmental risk that only a clinician who was in the home would know.
Open
Visit Intelligence
Prior Visit → This Visit  ·  Thu Jul 24  ·  From last clinician notes  ·  2 items need action before you start
4
Patients on service
2
Require MD contact
9
AI-captured insights
1
Safety flags
Intelligence captured from prior visits · 3 patients
Clinical Escalation Home Environment Safety Flags What Chart Won't Say
Inherited from ShiftIQ · Pain Pattern
She says 4/10. Treat it as 7. Six documented entries across 22 SNF shifts. Do not time her pre-therapy medication off her self-report. Premedicate 45 minutes before every PT session based on observed pain, not the number she gives you.
Inherited · 6 SNF entriesVerified across 22 shifts
Inherited from ShiftIQ · Fall Risk Recalculated
She will not ask for help. Three unassisted transfer attempts in the SNF when she thought staff were busy. A call light and a hallway of nurses made that survivable. Alone at home it is the most likely cause of a readmission in the first two weeks. Prioritize the home safety evaluation today.
Inherited · 3 attempts documentedRisk escalated for setting
See all 5 inherited insights and how they translated from the SNF
Care Transition →
Clinical Escalation
Dorothy is minimizing her symptoms. Weight up 3 lbs in 48 hours, bilateral ankle edema worsening, SOB with ambulation to bathroom. She attributed it to "salty food." She's been taking Lasix every other day — skips it on errand days because she doesn't want to need a bathroom while out.
J. Torres RN · 7/23 visit AI-flagged escalation MD call required today
What the Chart Won't Say
Her daughter Linda is the real medication manager. Dorothy is more adherent when Linda is involved. Linda wasn't there last visit and Dorothy was visibly more anxious. Linda needs to understand the weight gain is Lasix-related — Dorothy listens to her more than she listens to us.
Pattern: 3 visits Call Linda today
Safety Flag
Large German Shepherd — loose in the home. K. Osei had to wait outside 10 minutes last visit. Call James when you're 10 minutes out so he can contain the dog before you arrive. (970) 555-0318. Do not arrive unannounced.
Call 10 min before arrival
Wound Change · Possible MD Contact
Wound bed appearance changed since last week. Darker tissue at margins, more serosanguineous exudate than previous two visits. He's been weight bearing in the garage — neuropathy means he genuinely doesn't feel pain, which is why "it feels fine" is not reassurance. Compare to 7/22 photos before documenting.
K. Osei RN · 7/22Possible Dr. Morrison contact
What the Chart Won't Say
Rosa says 3/10. Treat it as 6/10. Consistent underreporter across all 6 prior visits. D. Park stopped asking and started watching — she visibly winced during a pivot while saying 3/10. Granddaughter Marisol softens answers in translation. Watch movement quality and facial expression, not the number she gives you.
Pattern: 6 visitsDon't use self-report as proxy
Home Environment · Fall Risk
New throw rug in bathroom — not there Monday. D. Park noted it at visit 6. Rosa nodded when it was mentioned but D. Park wasn't confident it would be removed. Be specific: remove it, fold it, put it in the closet while you're there. Don't leave without it gone.
Remove during this visit
Patient Quick View
Mary Johnson  ·  8:00 AM
SOC · From SNF · 5 insights inherited
SOC
Dorothy Chen  ·  9:15 AM
CHF · Weight +3 lbs · Lasix skipped
Urgent
James Whitfield  ·  11:30 AM
Wound changed · Dog: call first
Watch
Rosa Mendez  ·  2:00 PM
Post THA PT · Pain underreporter
On track
How this was built
VisitIQ read prior visit notes from J. Torres RN, K. Osei RN, and D. Park PT — extracted the soft intelligence that doesn't transfer between visits and organized it for the next clinician before they leave for the first home.
Clinical escalations flagged2 patients
Safety flags surfaced1 (call before arrival)
Environmental hazards1 (bathroom rug)
Chart-blind patterns3 patients
MD contacts required2 today
All four patient profiles are ready to explore.
Each shows a different dimension of VisitIQ's intelligence layer — click any row to open the full chart.
Patients on Service
Morning Route  ·  Thu Jul 24  ·  4 patients  ·  1 start of care  ·  2 need action before first visit
8:00
AM · SOC
Mary Johnson Start of Care 5 inherited
78F  ·  L-Hip Fx Post-ORIF  ·  DNR  ·  Dr. Patel
Transferred: Sunrise SNF 201A  ·  Discharged 7/24  ·  22 shifts observed
Visit 1 of 12 · SOC + OASIS
Ambulates 45 ft w/ RW · min assist
Says 4/10 → treat as 7 Won't ask for help Morning PT only
9:15
AM · Visit 4
Dorothy Chen Urgent MD call today
78F  ·  CHF, HTN, T2DM  ·  Post-hospitalization  ·  Dr. Patel
Last clinician: J. Torres, RN  ·  7/23/26
Weight +3 lbs / 48 hrs
O2 sat 93% · Edema 2+
Lasix non-adherence Daughter not present SOB with ambulation
11:30
AM · Visit 6
James Whitfield Watch ⚠ Call first
67M  ·  T2DM, Peripheral Neuropathy  ·  R Heel Ulcer Stage II  ·  Dr. Morrison
Last clinician: K. Osei, RN  ·  7/22/26
Wound appearance changed
A1C 9.2 · Non-offloading
Dog loose: call ahead Weight bearing garage Darker wound margins
2:00
PM · Visit 7
Rosa Mendez On track Pain underreporter
83F  ·  Post R THA, Osteoporosis  ·  PT/OT  ·  Dr. Okonkwo
Last clinician: D. Park, PT  ·  7/21/26
Ambulating 30 ft w/ walker
Goal: 100 ft by visit 10
Says 3/10 → treat as 6 New bathroom rug: remove Interpreter: Marisol
Action List  ·  Today
5 open items across 3 patients  ·  2 require physician contact today
Urgent · Dorothy Chen
Call Dr. Patel — weight gain + Lasix non-adherence. Report: 3 lb gain in 48 hrs, 2+ edema, O2 93%, SOB with ambulation, Lasix every other day. (970) 555-0147
Before noon
Call Linda Chen (daughter) — involve in Lasix plan. Explain weight gain is medication-related. (970) 555-0203
Today
Consider moving next visit to Friday — current next visit Monday. If weight continues up, Friday gives a data point before the weekend.
After visit
Watch · James Whitfield
Call James 10 min before arrival — dog containment. (970) 555-0318. Do not arrive unannounced.
Before visit
Photograph wound + compare to 7/22 — if change confirmed, call Dr. Morrison before leaving home. (970) 555-0229
This visit
On Track · Rosa Mendez
Remove bathroom throw rug — do it during the visit, not as a recommendation. Frame as protecting her hip progress.
This visit
Mary Johnson
78F  ·  L-Hip Fx Post-ORIF  ·  Start of Care  ·  Visit 1 of 12  ·  8:00 AM  ·  DNR on file
Transferred from SNF
Know Before You Knock
5 inherited
Carried forward from ShiftIQ · Sunrise SNF · 22 shifts · discharged today
Says 4/10 → treat as 7Won't ask for helpTylenol > morphinePatricia decidesMorning mobility only
1
Assess her pain by watching, not asking. Six SNF entries say she reports 4 while grimacing and guarding at 6 to 7. This matters more today than any other day, because the OASIS pain item you code in this visit funds the whole 30-day period.
2
Build the home around the fact that she will try it alone. Three unassisted transfer attempts in the SNF. There is no call light here. Prioritize the safety evaluation and set up the bathroom and bedside on the assumption nobody will be there when she decides to stand up.
3
The discharge med list defaults to PRN morphine, and the SNF evidence says scheduled Tylenol ES worked better. Four shifts of documentation. Call Dr. Patel today, before the first PT session, so therapy starts on the regimen that already worked.
4
Reach Patricia during this visit. She holds the DNR and Mary won't decide anything without her. She visited twice in 11 days. The first time you need her should not be the first time she hears your name.
5
Every PT visit goes before noon. Morning sessions in the SNF averaged nearly double the afternoon ambulation distance. Get this into the route builder today or the schedule will be set without it.
T. Martinez, RN · Sunrise SNF · Discharge note 7/24
"I want whoever picks her up in home health to know that she is going to tell you she's fine and she is going to try to do things by herself and both of those are the same problem. She apologized to me twice for getting up alone and then did it again the next morning. She isn't difficult, she just doesn't want to be a bother. If you build her house like she's going to ask for help, she'll fall."
Discharge Status · From SNF
FromSunrise SNF · Room 201A · 2-North
Length of stay11 days · admitted 7/13
SurgeryL hip ORIF · 7/11
Weight bearingWBAT per Dr. Patel
Functional at DC45 ft with RW · min assist
IncisionHealing · staples out day 9
Code statusDNR · Patricia is decision maker
SOC Priorities
4 today
OASIS pain item — code by observation and function, not self-report
This visit
Home safety evaluation — assume unassisted transfers
This visit
Call Dr. Patel — morphine vs scheduled Tylenol ES
Today
Reach Patricia — DNR holder, establish contact now
This visit
Set PT visits to morning slots in route builder
Today
Dorothy Chen
78F  ·  CHF  ·  Visit 4 of 9  ·  9:15 AM  ·  Last: J. Torres, RN 7/23
Urgent · MD call today
MD call required today — 3 lb weight gain, Lasix non-adherence, O2 93%, bilateral ankle edema worsening
Know Before You Knock
3 flags
AI-generated briefing from J. Torres visit notes · 7/23
Weight +3 lbsLasix skippedDaughter absentSOB with ambulationAnxious without Linda
1
Weigh her first, before anything else. Don't mention the weight or the Lasix until you have the number. A clean data point before any intervention is the most important thing you'll do this visit.
2
Ask about the garden before you ask about her health. She'll give you more if you spend 5 minutes just talking first. She mentioned her tomatoes last visit — start there.
3
Don't lecture about the Lasix. Find out what's actually in the way. She skips it on errand days because she doesn't want to need a bathroom while out — that's solvable if you understand it.
4
Linda is the medication manager. Dorothy listens to Linda more than she listens to us. If Linda wasn't there, find out why — and call Linda today after the visit.
J. Torres, RN · 7/23 · 2:14 PM
"She said she was feeling okay but when I helped her to the bathroom she was short of breath by the time she got back to the chair. She didn't want me to write that down. I wrote it down. Her ankles were definitely puffier than last week. Linda needs to know what's happening with the Lasix — Dorothy listens to her more than she listens to us."
Actions Required
2 today
Call Dr. Patel — weight, edema, Lasix non-adherence, SOB. (970) 555-0147
Before noon
Call Linda Chen — involve in Lasix plan. (970) 555-0203
Today
Consider moving next visit to Friday — confirm after MD call
After visit
Vitals Trend
Weight
190
↑ +3 lbs / 48 hrs
BP
148/92
↑ from 138/84
O2 Sat
93%
↓ from 96%
HR
84
↔ stable
Medication Compliance
Non-adherence
Furosemide 40mgEvery other day — ~50% this week
Lisinopril 10mgAdherent
BarrierSkips on errand days — bathroom access
James Whitfield
67M  ·  R Heel Ulcer Stage II  ·  Visit 6 of 12  ·  11:30 AM  ·  Last: K. Osei, RN 7/22
Watch · Wound changed
Safety: Call James 10 min before arrival · German Shepherd loose in home · (970) 555-0318
Know Before You Knock
Safety flag
AI-generated briefing from K. Osei visit notes · 7/22
Dog: call firstWound changedWeight bearingCarol needs support
1
Call when you're 10 minutes out. James needs time to put Rex in the back room. (970) 555-0318. This is a non-negotiable safety step.
2
The wound looked different — compare to 7/22 photos before you document anything. Darker tissue at margins, more drainage. If change is confirmed, call Dr. Morrison before leaving the home.
3
"It feels fine" is not reassurance. He doesn't feel pain because the neuropathy has already damaged the nerves. Absence of pain is the danger, not the protection — tell him that directly.
4
Spend 10 minutes with Carol. She's managing the wound between visits and she's overwhelmed. She needs specific watch-fors: redness spreading, warmth, odor, fever — and a number to call.
K. Osei, RN · 7/22 · 3:47 PM
"The wound looks different — I can't say it's worse exactly but the color at the edges is darker than it was last week and there was more drainage on the dressing than I expected. He was cheerful and cooperative but I found out halfway through the visit that he'd been in the garage for two hours that morning standing on it. He genuinely doesn't understand that not feeling pain doesn't mean he's not causing damage. Carol pulled me aside when he left the room and asked if she should be worried. I told her honestly that I wasn't sure yet. I think you need to be."
Wound Status · R Heel
Changed 7/22
ClassificationStage II · Pressure/Diabetic
Size (7/22)2.1 × 1.8 cm
Wound bedCHANGED — darker at margins
ExudateIncreased serosanguineous
Odor (7/22)None · reassess today
Pain reported0/10 · neuropathy · do not use as proxy
A1C (7/10)9.2 — impairs healing
Actions · James
Call 10 min before arrival — dog containment. (970) 555-0318
Before visit
Photograph wound · compare to 7/22 — if changed, call Dr. Morrison. (970) 555-0229
This visit
Neuropathy education — different frame this visit
This visit
Spend 10 min with Carol — wound watch protocol
This visit
Rosa Mendez
83F  ·  Post R THA  ·  PT Visit 7 of 14  ·  2:00 PM  ·  Last: D. Park, PT 7/21
On trackPain underreporter
Know Before You Knock
2 flags
AI-generated briefing from D. Park visit notes · 7/21
Says 3/10 → treat as 6New bathroom rugMarisol softens in translationAmbulating 30 ft
1
Stop asking about pain. Start watching. Rosa says 3/10. She means 6. She visibly winced during a pivot last visit and still said 3. Read her face and her movement pattern — hesitation, guarding, shortened stride are your real pain scale.
2
The bathroom rug needs to come out today. It wasn't there Monday. D. Park mentioned it but wasn't confident it would be gone. Be specific: remove it, fold it, put it in the closet while you're there. Don't leave without it gone.
3
Ask Marisol directly. When Marisol says "abuelita says she's fine" — ask her: "Does she look comfortable to you?" That question usually gets a more honest answer from both of them.
4
Tell her specifically what's improved. "Your hip extension is better than last week" means more to her than "you're doing great." D. Park said she worked 15% harder after a specific compliment last visit.
D. Park, PT · 7/21 · 4:22 PM
"Rosa is doing well — genuinely well — but I don't fully trust her pain reports. She smiled and said 3/10 while visibly wincing when she pivoted. I stopped asking and started watching instead and got a much clearer picture. Marisol is wonderful but she is absolutely filtering. The rug in the bathroom needs to go — I brought it up and Rosa nodded but I'm not confident it'll be gone by your visit. Be specific: remove it, fold it, put it in the closet, today, while you're there."
Functional Progress
On track
Ambulation30 ft w/ walker at visit 6 · up from 15 ft visit 1
Goal100 ft by visit 10 · needs ~14 ft/visit
TransfersSit→stand: min assist (was max assist visit 1)
Hip precautionsCompliant all 6 prior visits
Reported painConsistent 3/10 · clinician-observed 5–7/10 with activity
Actions · Rosa
Remove bathroom throw rug — during visit, not as recommendation
This visit
Full home safety walkthrough — check for additional fall hazards
This visit
Measure and document ambulation distance against visit 6 baseline
This visit
Teach Marisol: what to watch for between visits and when to call
This visit