How to do proper rehab nurse notes or documentation?

I work in a rehab one day a week. However, they use a form that targets the patient's abilities to feed, clothe, bathe and transfer themselves or the level of assistance that they require. In fact, we do not do a narrative note on the patient unless there is an issue to address. Otherwise, everything is documented by a one/two word answer or by checking off a box that applies to the patient. I suggest that you ask your manager to clarify what you are doing wrong so that you know what is being expected of you. If you are not comfortable with this, then ask a trusted co-worker. Good luck with your nursing career! It gets better.

Good luck! Happy Holidays!

We always did a narrative note, IN ADDITION to the FIM check list.
In my narrative, I charted head to toe assessment, VS, prn meds, & any changes in functional abilities, dressing changes...

I also do rehab nursing and have for about 16 years. It is very important to document just how much you are doing for the patient and how much he can do for himself. Is he minimal, mod, or max assist? Are you assisting with dressing, donning his shoes and socks, pulling up or down his pants? Do you feed the patient or is he able to feed himself? Is he able to toilet himself or are you assisting with pulling up and down his pant. Do you get the drift? If there are MDS's being done in your facility, this also is a wonderful way to help the MDS nurse do accurate documentation to capture everythng about the patient. Remember to chart whether the patient does this for everyone, or just you, the therapist, or their family. Some patient's try to pull the wool over your eyes and take advantage of someone helping them with their adl's. They need to do what they can physically and not depend on you to do it for them. How many times have we all heard, "you're getting paid to do it so I'll let you do it". Believe me, NONE of us get paid enough to do half the things we do !! susie_nurse

Rehab nursing should focus on specialized rehab nursing functions: medication educ. programs,bowel and bladder programs and nursing interventions related to comorbidity. This type of documentation covers the need for 24 specialized rehab nursing and medical necessity related to the treatment of active comorbidities. It is crucial for this to be present in your nursing notes. Fiscal intermediaries will review charts for this type of documentation not just their level of function etc.

"you're getting paid to do it so I'll let you do it". Believe me, NONE of us get paid enough to do half the things we do !! susie_nurse

LOL... Those patients were always such a joy. I liked to respond to that one with a perky, smiling face..."yes, but you won't be taking me home with you, & paying me to dress you at home, so let's see what you can do on your own & I'm right here if you need further assistance."