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The visit note built for speed, not paperwork.
When you're seeing four or five clients in a day, you don't have time to work through a multi-page assessment packet at every stop. This is the note I actually use in the field — one page, mostly checkboxes, organized the way a real visit unfolds: history, assessment, what you did, what you taught, and what's next.
What's inside:
Client & visit information block (name, DOB, visit location, referring provider, diagnosis/referral reason)
Relevant history — diabetes, PVD, neuropathy, anticoagulant use, other conditions, medications
Structured assessment — skin, nails, circulation, sensation, temp/color, deformities
Interventions performed — nail care, callus/corn care, skin care, and other services, with a details field
Education provided checklist
Plan / follow-up with return-interval options and referral checkboxes
Nurse signature, credentials, and license number line
Format: Delivered as a print-ready PDF and an editable .docx you can adapt to your own practice or EHR-adjacent workflow.
How this is different from the Clinical Documentation Pack: The Documentation Pack is four separate forms for a complete clinical record — a full SOAP note, a comprehensive baseline assessment, a diabetic monofilament screening, and an ongoing care plan/visit log. This Visit Note Template is a single, faster form for routine visits where you need solid documentation without the full multi-form workup. Many nurses use both: the Pack for new clients and periodic reassessments, this template for routine follow-ups in between.
Scope note: Like all RNscrub Foot Care documentation tools, this template is a starting point — adapt it to your state Board of Nursing documentation requirements and your own practice's scope.
The visit note built for speed, not paperwork.
When you're seeing four or five clients in a day, you don't have time to work through a multi-page assessment packet at every stop. This is the note I actually use in the field — one page, mostly checkboxes, organized the way a real visit unfolds: history, assessment, what you did, what you taught, and what's next.
What's inside:
Client & visit information block (name, DOB, visit location, referring provider, diagnosis/referral reason)
Relevant history — diabetes, PVD, neuropathy, anticoagulant use, other conditions, medications
Structured assessment — skin, nails, circulation, sensation, temp/color, deformities
Interventions performed — nail care, callus/corn care, skin care, and other services, with a details field
Education provided checklist
Plan / follow-up with return-interval options and referral checkboxes
Nurse signature, credentials, and license number line
Format: Delivered as a print-ready PDF and an editable .docx you can adapt to your own practice or EHR-adjacent workflow.
How this is different from the Clinical Documentation Pack: The Documentation Pack is four separate forms for a complete clinical record — a full SOAP note, a comprehensive baseline assessment, a diabetic monofilament screening, and an ongoing care plan/visit log. This Visit Note Template is a single, faster form for routine visits where you need solid documentation without the full multi-form workup. Many nurses use both: the Pack for new clients and periodic reassessments, this template for routine follow-ups in between.
Scope note: Like all RNscrub Foot Care documentation tools, this template is a starting point — adapt it to your state Board of Nursing documentation requirements and your own practice's scope.
