Skilled Nursing Visit Notes Example: Fill & Download for Free

There are many different areas of physical therapy/physiotherapy including:* Inpatient acute care: where you work in a hospital to assist people with either returning home or helping them determine the next level of care. When you come in the morning you will make a schedule or see what your schedule looks like for the day and then work to see the people on your list. Each hospital has a different method for determining the schedule but the main goal is to assess what someone can achieve to determine if they would be safe to return to their current living situation and make recommendations for safety. If someone is not safe to return to their prior living arrangement therapy will provide recommendations such as going for rehab at an inpatient facility or recommend family support/assist. Hospitals are meant for short term stay so while we work on strengthening, balance, etc the focus is making sure people are ready and safe to leave. Hospital treatments can include crutch training, teaching how to use a walker or cane or how to safely get out of bed after surgery/injury/illness. Education is a big portion of therapy and frequently includes surgical precautions, education on safety with mobility, education on importance of getting out of bed while in the hospital to prevent muscle weakness and atrophy for some examples.*Rehabilitation: I am speaking from a United States perspective as to what rehab provides but it is typically split into 2 categories of acute rehab, which is considered intensive 3 hours/day short term stay, and sub-acute rehab, for people who can not tolerate 3 hours/day due to medical issues and will require a longer stay. Rehab can include Occupational Therapy, Speech Therapy, Recreational Therapy and as they are staying there you have nurses and nursing assistants. The doctors make rounds and there are team meetings to discuss patient progress. At rehab a therapist will typically carry a caseload of patients that they oversee treatment for and you will spend more time with each person and build more of a relationship than you would in the hospital. It is often stated that therapists spend more one on one time with patients than the nurses as they are in charge of multiple people at one time. Building the relationship becomes important if you consider how trust is needed to ask sensitive questions such as “will I be able to have sex again?” after a spinal cord injury. It is very rewarding to see people make progress and return home but you also recognize that not everyone will. There are multiple factors at work including psychological or cognitive barriers, severity of disease, amount of support available to the person, home set up. This setting is where I first questioned whether I did enough to help them or not but that is where talking with other therapists helps and trying to keep up on the latest research. Therapists will frequently share their experiences and cases with each other to help brainstorm ideas or make changes to plans of care.*Home Care: Therapists make home visits and in the U.S. it is typically 1–3 times a week. There are challenges with home visits that include you are required to drive and bring your equipment with you. You are also limited by the space available in a persons home for what you can do to work toward reaching the patient’s goals. Typically home care is recommended after a hospital discharge or rehab discharge as a way to continue to make improvements. Many of the home therapists I have talked to state that they will end up taking their notes home with them to finish. There is some flexibility to your schedule and most home therapists create their own schedules.*Outpatient: Your schedule in outpatient is typically determined a week or two before as people have to agree to come in at that time. While some may try to schedule a month out the schedule can always change and people might call the day before or day of and if you have an opening due to a cancellation it becomes filled. You will typically have some evaluations every day for initial visits to assess and determine what is wrong and what the plan of care is.*School based pediatric: Some therapists work in a school setting with children and will see the children either one on one or in a classroom or group setting depending on the goals.There is also Long-term acute care setting which is a step down from the hospital for people who require increased medical care that can not be provided at a rehab but there is not a reason to remain at the hospital they are currently at. Therapy is typically provided at these settings but is similar to a rehab setting in how therapy is set up. Skilled nursing facilities are similar to sub-acute settings as far as how it is run on the therapy side and will frequently have long-term setting with a sub-acute section.Part of therapy no matter what setting you are in involves paperwork. It is the part I dislike the most (probably because it involves sitting still) but also the most important. My teachers in school used to state that if you don’t write it down it did not happen. The documentation is very important as you need to be able to state why you are needed, what you are doing and show whether there is progress. In some settings you are required to send paperwork to the doctors for signatures or send for insurance authorizations. You also have to complete billing as it is important if you want a paycheck and the clinic needs money to be able to stay open. To see a patient you typically have a script from a physician/nurse practitioner/physician assistant however some states in the U.S. now have direct access. With direct access patients are allowed to come to an outpatient clinic without a script to be evaluated. Each state has their own rules as to whether therapists have direct access and to what extent.Therapists are typically good advocates for patients and will voice to doctors, social workers, insurance companies, etc what they feel they need. We make phone calls or send emails to physicians/nurse practitioners/physician assistants regarding change in status or regarding needs of the patient. We contact insurance companies to fight a denial. A challenging aspect for allowing a person to be as independent as possible is money… People may not be able to afford a wheelchair or walker or hospital bed, etc but insurance is not willing to pay for it or they do not have insurance. Sometimes there are resources available to refer them for help and sometimes not. Therapists have also been known to be creative to help the patient save money by coming up with another solution rather than something they are unable to afford. I met a therapist that would make a bed rail for $10 so patients wouldn’t have to go and buy one that costs $30 or more. Patients have also been known to come up with amazing ideas as well. I have had patients tell me that they liked doing the stepper and made themselves one to work on it at home. Another barrier we face is how many visits we are allowed. Insurance is looking for ways to remain cost effective and there are plans that require a $90 (US dollars) copay or only allowed 10 visits in a year. If a patient has a new head injury and has not recovered enough to return to work how do they cope? Often they cannot afford to pay out of pocket for therapy. Some people will put therapy on hold when it is the last few months of the year to wait for their benefits to start over. Money is a big barrier we face when providing care.People are all different in their beliefs, personalities and lifestyles which allows us to have amazing personalities to work with on a daily basis. Are some people challenging to us? Yes! But sometimes it is because we are having a bad day or the person is having difficulty coping with what is going on. You need an open mind. I have had many times where I have walked into a room to have someone yell at me that they do not want to get out of bed and that they hate therapy. Taking the time to talk with them and be open makes a huge difference. I had one patient tell me “I’m sorry” later in the session and explain that they had a bad morning due to pain at night and not sleeping. There is a learning curve to figuring out if you are wasting your time and the patient’s time by staying and trying to encourage them to participate. Not everyone will change their mind. It is a lot of fun when you get to joke with people. I have frequently told patients who are nervous (and can take a joke) that I won’t let them fall because there is too much paperwork involved if that happens. You learn what motivation is and how some people do not give up while others think their life is over. You can see 2 people with the same issue have different outcomes due to how much effort they apply.Continuing education is a requirement in the United States and some therapists pay for all of it while some receive money from their employer to cover some or all of the courses. Courses can range in cost from free to $20 or $100–$600 with some I’ve seen being over $1000 US dollars and courses can be a weekend, a week, a day or a couple of hours either self study or classroom setting. Some companies will even provide courses for their employees.It is difficult to get into what an evaluation or treatment would involve as it is different for each patient depending on setting, diagnosis and prognosis. You might be working with a patient with orthopedic issues, sports related issues, neurological issues, lymphedema management, pediatric, etc. There are also many different theories and methods for completing treatments and therapists even have the opportunity to specialize in an area if they are interested in doing so. You can become a therapist specialized in neurological disorders and can sub-specialize by focusing on Traumatic Brain Injuries or Vestibular or Spinal Cord Injuries for example. There are therapists who are sports specific and work in an outpatient clinic or with sports teams for schools, etc.The work can be challenging but the rewards of being able to help people reach their goals and return to their lives makes it worth it. I had an opportunity to watch an 82 year old man who had a stroke return to walking and eventually golfing. The excitement of having someone tell your their success stories when you see them such as “I was able to go to the bathroom by myself today” or “I walked 4 blocks today with my cane” can make your day change from bad to good as you celebrate with them. There are multiple factors involved in the success of a patient’s rehab from medical limitations, motivation, money or questioning whether you did enough but if I didn’t work as a physical therapist/physiotherapist I would not have had the opportunity to help make a difference in peoples lives and meet amazing people.

Yes, numerous times. I think it is important to note that they did not normally disbelieve the symptoms but did not put the puzzle pieces together correctly. This has happened as I’ve also correctly diagnosed family many, many times as well. I often used Net but also have a useful background so don’t “rely” on it alone.I figured out things some docs would still want to argue about, such as subclinical hypothyroidism—but things improved upon medication and SOME docs do believe in it and some do not.I figured out something NOT debatable: peripheral neuropathy. My PCP agreed but to have a diagnosis you need a neurologist. Was only one on the insurance. Went to him and said the tentative diagnosis was PN. He IMMEDIATELY said, “You don’t have peripheral neuropathy.” He had NOT looked at the referral notes nor examined me! I don’t recall what I said exactly but was clear he did need to do the test. Big sigh. He did test. Return visit: “You have peripheral neuropathy.” Well thank you, Sherlock. Treatment? None. “Come back if it gets worse.” Really? He is an example of a doctor that really is, to be overly generous, of pedestrian skills at best.I figured out PFMD—Pelvic Floor Muscle Dysfunction. Again when I presented that to my PCP for consideration he said, “Yes, fits.” Sent me to a Urogyn who is REALLY good and I had sent him useful info in advance (including ruling out some of the logical differential diagnoses so we did not waste time. Have NO STIs, for example, and never have, but that could cause some of the issues.) He thanked me for the info when he walked in for that consult. Said I’d saved him hours of research (had printed out assorted labs, notes, etc. for fast reference.) Did a brief exam. Concurred that was the problem but we needed a bit more info. Scheduled a test my PCP could not have ordered. Had it. Confirmation. Was good enough to go with my initial request in my pre-visit notes: let’s skip meds and try PT. Did that. Significant improvement. Much appreciated when there are docs who are CONFIDENT (and should be) so they’re not upset when the patient provides info. Also he was not married to a prescription pad. Though he’s a surgeon, was OK with my wanting to avoid surgery if it would be practical to do so. Wonderful doctor.There have been other things (not the healthiest person). PCPs have been good and listened. MOST specialists were competent. SOME had to be argued with a bit to do appropriate testing, but when the results presented themselves and exams bore those results and diagnoses out, they made the diagnosis.Have had a few doctors who are NOT good, at least not with me. Sometimes was nothing to argue about IF they would have done a proper exam. Who knows what the issue was, but one ER doc who REFUSED to do a proper exam when I told him I was impacted was not a happy camper when the nurse walked in several minutes later to find me disimpacting myself, with shall we say, impressive results. Coward refused to come in; nurse provided me with additional requested supplies as I had proven the diagnosis and assisted me and I was able to complete what needed doing before leaving. I did follow up with a complaint to the hospital. Not sure what the outcome of that was, but was saddened to see that he was considered by some publication as a “top doc” for the ER! Sure he was competent with MOST problems; absolutely did NOT impress me one bit for rather obvious reasons. I was in the ER for well over an hour; it was NOT that busy; he should have come in at some point and spoken with me when it was clear he had been 100% wrong. Not sure he learnt all he should; if another patient without skills could have been discharged only to need far more treatment soon after (when you also cannot urinate it IS a medical emergency and things can go very wrong in a surprisingly short amount of time) that would be beyond inexcusable.Those who are ridiculous, as he was, when it’s really NOT something that can be faked nor is it that hard to determine (unpleasant but not “hard” to determine) if it is the correct diagnosis or not, are very frustrating.Most of my trips to ER (usually with family members) have been good: doctors HAVE overall been receptive to the pertinent info being presented as well as open to the major concern/tentative diagnosis. VERY helpful when personnel at desk are also professional and on the ball. Had to take my cardiac patient father in more than once and being able to get him out of the car via wheelchair and prioritized with doc who listened to report along with medical history would result in prompt, appropriate treatment and hospitalizations that were briefer than they would have been if we had someone who refused to LISTEN.Don’t think any of the diagnoses were really all that “exotic.” So many things work against proper diagnosis these days: too short visits, reliance on going to prescriptions to “deal” with symptoms as opposed to getting to the root of the issue, struggles at times with pre-auths to get appropriate testing necessary to have confidence in a diagnosis, and more contribute to making it difficult to be a real diagnostician. Much of that could be addressed by getting the handcuffs off doctors. Only so many hours in a day and when you waste so much time on things that really are not about patient care but about paperwork to satisfy interlopers it is hard to do your real job. Lots of patients coming in with highly unlikely diagnoses or demands for prescriptions adds to the fun.

To clarify the question: "qualify for skilled nursing care" I believe you mean you do not meet the criteria of the local authority to receive funded care placing you in a nursing home. As such you have an identified care related need which needs to be addressed by some degree of help and support.Firstly, I would encourage you to engage with your Local Authority social services team again and request an assessment if you have not had one yet. Based on the question, I expect you have had an assessment which has given the above determination. It might also mean that you have not qualified for any form of funded support from the local authority as your needs have not been adjudged to be "substantial or critical enough" to warrant the paid for support you are looking for.This said please do not disregard any assessment and use this to get a greater understanding of your needs as they will have been produced by a competent professional with your best interests at heart, and might include some alternative options.Indeed, if you do not qualify for nursing care as you put it, you may qualify for a small amount of visiting hourly home care, which can support with bathing and dressing. Having an identified care need is usually defined as not being able to carry-out the basic activities of daily living without support. This includes activities like; dressing and feeding and also include personal care (bathing). If indeed you have mobility issues and need to have your home adapted to make it more suitable, I would again engage with the local authority, explain the situation/risks, for example in bathing, and the Local Authority have funds to cover basic home adaptation to ensure it is a safe environment. This might be as little an intervention as installing grab rails to aid mobility, but could go as far as adaptations to the bathroom to make it suitable and safe to use. Again the need and qualification for this will depend on their assessment, but small adaptations (typically under £2k) can still be requested.In terms of other 'venues' that might be considered to provide the care you need, there are a number of considerations. There are (a) different environments as you started to identify, but also (b) other care arrangements which might allow you to remain in your existing environment, safely for longer.To address your question directly (a) there are a number of other environments which provide varying levels of support and care as part of the living arrangements. These include sheltered accommodation and assisted living with varying levels of support. Many people consider selling their existing homes and, if they have equity within them, use this to then buy a new home in one of these schemes. Before doing so, you should consider what your long-term care plan is, because it will have an impact on what services you can commission in addition to what is available - for example you can’t get live-in care in the future if you no-longer have a spare bedroom for example.Note above we focused on the needs assessment provided by the local authority, but there is also a financial assessment which follows, which if you are determined to have a substantial or critical need which makes you eligible for care services, you are then assessed financially to see if the Local Authority will fund this. I mention this now because before selling a home or making any changes which involve your personal finances, we believe it might be worth speaking to a specialist financial advisor with a Society for Later Life advisor (SOLLA) accreditation. This is because, if for example you do not currently qualify for funded care, but are near the threshold (£23,250 in England and subject to change/individual person circumstances - see money advice service for updated figures) then by selling your home the value received in this may then be part of the equation in assessing whether you qualify for funded care. Getting the right advice, thinking through your long-term care needs and indeed how you want to be cared for is important and the right planning will maximise your options.(b) In terms of other services to support with activities of daily living, small adaptations to the home can make the environment more suitable, and then getting in some home care may provide the support needed and help to maintain your independence. It is more affordable than residential care alternatives and is a less drastic intervention. Within home care there is visiting hourly day care, night care and live-in care. These vary in price across the UK and you can use the BBC care calculator to get a clearer estimate of what to expect in your area.By way of full disclosure, I am the director of a care business called SuperCarers, www.supercarers.com. We are an introductory service connecting families with the best local care providers in their area and sometimes this is more affordable than using a traditional care agency. You might also want to connect with a CQC regulated managed care offering if you want a fully managed care service.I hope this is helpful