Harmony Healthcare Blog

Skilled Nursing Documentation and the Continuum of Patient Care

Posted by The Harmony Team on Sat, Jun 01, 2013

Edited by Kris Mastrangelo

Often times, clinical records reflect the limited skilled nursing documentation representing the critical thinking of a licensed nurse. The documentation that supports the ongoing skilled nursing care including the risk of exacerbation of medical signs and symptoms. Consider patients who require a continuum of care and may present as medically stable, however, require education and preventative treatment to promote optimal health and wellness. 

Examples include:

  • Patient will verbalize understanding and demonstrate carryover of medication teaching
  • Patient demonstrates ability to ____ in resuming self-care following this change in health status
  • Patient is able to verbalize signs and symptoms of _____ that would precipitate need to inform physician immediately
  • Patient able to provide return demonstration on _____ to enhance ability to maintain health status
  • Patient verbalizes understanding and is able to demonstrate return teaching on _____
  • Patient verbalizes understanding and is able to provide return teaching on signs and symptoms of disease exacerbation that would require immediate medical attention (at the ER)
  • Patient is currently working with skilled rehabilitation services and is able to/unable to perform ______ (Functional performance task) with ____ (level of assistance) requiring assistance from nursing staff with improvement/decline and is working towards discharge goals

By providing continuing care while the patient becomes stable medically, and continuing to work in collaboration with rehabilitation services to optimize functional independence, nurses have the opportunity to focus on patient education, which is a daily skilled service and provides a higher likelihood for patient success in the community.

Skilled Nursing educational areas include:

  • Medication management
  • Understanding signs & symptoms of medical conditions
  • Educating patient on disease risk factors
  • Educating patient on important medical questions to ask at healthcare appointments

Using an educational intervention plan to assist in the transition process from short term rehabilitation to home has been shown to significantly reduce hospital readmission as far out as six months. 

Do your medical records support skilled care?

Tags: Medical Record Review, Skilled Nursing Documentation, Skilled Nursing Facility

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