Skilled Nursing Facility Therapy Documentation Guidelines


 

Setting a Definite Goal Helps in Skilled Nursing Facility Therapy Documentation
Doing an activity analysis is very beneficial

One of the key things that you need to keep in mind in skilled nursing facility therapy documentation is looking at your goal. And you can write a good note but it needs to be related to your goals. And if the patient is not making gains towards goals, there could be multiple different reasons. But it might, your note might be easier written if you go back and look at your goals because your notes should always be related to your goals. And your goals should support the progress that they're making in therapy.

If they're not making progress, change your goals. Go back and do a modification to your goals that may be decreases the incremental steps in which the person is going to achieve their long-term goal.

Long Term Care Training Expert Advice: Then look at what is the long term goal? Maybe you overshot. Maybe you were too aggressive in setting that goal. The patient you thought was going to do really well. But medically, they got too complicated. And so you need to back up. Or maybe the patient flourishes in rehab and somebody who you thought was going to be really low level ends up totally rallying, doing really well. And so, you need to amend your goals, set them a little bit higher for the patient.

But still, oftentimes, goals are set – they're not set at increment enough levels. And so, it makes note write hard because they're looking at trying to get the patient from a moderate assist to a minimal assist. Maybe the person hasn’t made gains.

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But maybe even though the person is moderate assist, they are still able to do better within the moderate assist level. They are showing better visual attention. Or they're able to initiate a task better even though they still need moderate assist. Those two things may be huge in terms of looking at the progress of a patient.

So not underestimating those small gains that the patient is making and actually acknowledging, recognizing and documenting them can be very supportive when you have a patient who's not really making the gains you expected.

And a way to do some of breaking down of your goals, and these ones can be applied to nursing and to therapies. It's looking at the amount of queuing that you're providing and the technique that you're providing for a patient.

So this could be your cognitively impaired patient or your psychiatric patient where whether they're on therapy or not, how much intervention is required. If you're constantly intervening with the patient, they're on 15-minute checks or they're on one on one. Well, that's constant intervention.

Long Term Care Training Tip: Maybe then they go down to frequent which is less than constant that maybe they reduced to occasional. And being able to use this terminology will be very supportive in how you are going to document your interventions and the fact that the person still continues to require daily skilled services.

And the type of interventions, so constant, is it constant verbal queuing? Is it constant tactile queuing? Maybe the patient goes from constant tactile queue. Always having to put your hand on Mrs. (Jones). “Oh, Mrs. (Jones)…” Maybe it's a feeding program and her attention is very poor and she's not able to feed herself. And so, you have to put your hand on her shoulder and verbally queue her.

“Mrs. (Jones), you need to take a bite. Mrs. (Jones), you need to take a bite.” And then maybe you're able to reduce that to not having to touch her shoulder but verbally continue on a constant level. And then maybe you're able to reduce that to a frequent level.

So really doing an activity analysis and looking at what are the components of the activity and can we identify anything that the person has done on a positive nature and looking at your own behavior in response to the patient’s challenges and how you're going to grade your own behavior is very supportive.

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