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To evaluate and improve the daily progress note template in rehabilitation nursing documentation.

Publication Date



nursing documentation, patient care


Other Nursing


Our Progress Notes Needed to Change

  • Organizational and regulatory documentation requirements are changing
  • Higher patient acuity, increased time restraints, and new technology created new challenges for nursing documentation
  • Medicare and private insurers required we prove the "worth" of our nursing services
  • Medical record audits highlighted the importance of nursing documentation to help support medical necessity
  • Rehab documentation requirements were not easily understood by nurses in other settings
  • Our own documentation policies worked best for acute units, rather than the unique environment of the rehab unit

Findings in the Literature

  • The U.S. Department of Health & Human Services estimated in 2004, Medicare paid $3.1 billion in rehab stays that had "inadequate documentation" (Hentschke, 2009)
  • Nursing documentation must support the need for a higher level of care than what is provided in a skilled nursing facility, or subacute setting
  • A Rehabilitation Nursing article (Hentschke, 2009) highlights the charting differences between settings
  • Rehabilitation documentation differs from acute care documentation and should minimally include: patient and family education, nursing interventions and patient responses, techniques learned in therapy sessions, burden of care and patient progress toward goals

Our Nursing Template

We created, revised, and put into practice a daily progress note template that:

  • Was easily adaptable for each patient
  • Allowed nurses document only on what was relevant that shift
  • Met Centers for Medicare and Medicaid Services (CMS) requirements to support medical necessity
  • Included the areas supported by the literature
  • Was compliant with the hospital's documentation policy
  • Prevented duplication with the electronic medical record
  • Added value for nurses, physicians, and our colleagues
  • Could be implemented easily and in a timely manner
  • Was intuitive for new staff, float staff, and students

A Practical Solution to the Challenges of Rehabilitation Nursing Documentation

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