Over the years, our documentation practices have evolved significantly—from paper charting to electronic charting, along with other adjustments designed to streamline processes and ensure compliance with vendor requirements.

I would like to take this opportunity to clarify expectations regarding the completion of Start of Care (SOC) paperwork. As a reminder, SOC paperwork must always be completed during the patient’s initial visit. Unlike the Standard Visit Note, the SOC documentation is more comprehensive and includes critical elements such as the Consent for Treatment and baseline Medication Reconciliation.

Accurate and timely completion of this paperwork is essential, not only for capturing vital patient information but also for ensuring appropriate reimbursement. The quality of what we submit to our vendors directly impacts how our work as nurses is credited. Please review the guidance below to ensure SOC paperwork is completed correctly and consistently. If you ever have any questions as to what visit note to you use, reach out in Teams for help. Please review the guidance below to ensure SOC paperwork is completed correctly and consistently.

Start of Care (SOC) / Admission Guidelines

1. When SOC/Admission Should Be Completed

• Anytime the nurse engages clinically with the patient

  • Examples: taking vitals, performing assessment, identifying issues after initiating patient interaction.

  • Rationale: Once clinical care begins, patient consent is required, and SOC/admission should follow to document and formalize intake.

2. When SOC/Admission Should Not Be Completed

• Visit ends before any clinical action occurs

  • Examples:

    • Patient is still hospitalized.

    • Medications/supplies not delivered and identified prior to clinical action being taken.

    • Nurse unable to access home.

  • Rationale: Without patient contact or clinical action, SOC/admission is unnecessary.

    
    
    
    

• Patient immediately refuses visit (before clinical action begins)

  • Examples: patient declines due to not feeling well, not wanting visit, etc.

  • Rationale: No clinical care provided, so SOC/admission is redundant.

Core Principle

👉 If the nurse “touches” the patient or performs any clinical action → obtain consent and complete SOC/admission.

👉 If no clinical action occurs → do not complete SOC/admission.

If you have any questions regarding this information, please feel free to reach out to me or a Clinical Supervisor directly in Teams. 

Thanks so much for all you do!

Sincerely, 

Shari Blackmon RN-C, BSN

Director of Nursing