What should be included in a comprehensive order list for a Skilled Nursing Facility (SNF) patient?

Comprehensive Order List for SNF Patients

A comprehensive order list for a skilled nursing facility (SNF) patient should include medication reconciliation, monitoring parameters, rehabilitation goals, and care transition documentation to ensure patient safety and reduce readmission rates.

Admission Orders and Documentation

• Document complete diagnosis list with clear identification of chronic conditions such as diabetes type and heart failure classification to ensure safe and effective care transitions 1
• Include recent vital signs, laboratory results, and pending tests to provide a comprehensive clinical overview 1
• Document recent procedures, treatments, and current clinical status to facilitate effective care transitions 1
• Specify advance care planning documentation including goals of care and resuscitation status 2

Medication Management

• Perform thorough medication reconciliation to prevent discrepancies that occur in up to 71.4% of SNF admissions 3
• Cross-check home and hospital medications, documenting any changes with clear rationale 1
• Include specific medication administration times, routes, and durations 4
• Document medication sensitivities and adverse reactions 1
• Specify insulin regimen and target glucose ranges for patients with diabetes 2
• Consider medication simplification for complex patients (e.g., extended-release formulations, once-daily dosing) 2

Monitoring Parameters

• Establish vital sign monitoring frequency (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation) 2
• For heart failure patients, include daily weight monitoring with parameters for when to notify providers about weight gain 2
• For diabetic patients, specify glucose monitoring protocol with target ranges and hypoglycemia management 2
• Include parameters for when to notify the physician (e.g., fever, changes in vital signs, acute mental status changes) 2
• Order appropriate laboratory monitoring for medications (e.g., renal function for ACE inhibitors, electrolytes for diuretics) 2

Disease-Specific Management

• For heart failure patients:

  • Include monitoring for symptoms and signs of volume overload 2
  • Specify target weight and instructions for proper weighing procedures 2
  • Document heart failure medications with clear titration plans 2

• For diabetic patients:

  • Specify consistent carbohydrate meal plans 2
  • Include instructions for administering prandial insulin after meals to match carbohydrate intake 2
  • Consider "block testing" (monitoring at different times of day) to identify glucose patterns 2

Rehabilitation and Functional Orders

• Specify physical therapy, occupational therapy, and speech therapy evaluations and treatment frequency 2
• Include activity orders (bed rest, up with assistance, ambulation as tolerated) 2
• Document mobility aids required (walker, wheelchair, cane) 2
• Encourage physical activity as appropriate to prevent deconditioning 2

Nutrition and Hydration

• Specify diet type (regular, diabetic, low sodium, renal, etc.) 2
• Include food substitution protocols if meal intake is <75% 2
• Document fluid restrictions or hydration goals 2
• Order nutritional supplements if needed 2

Skin and Wound Care

• Include pressure ulcer prevention measures 2
• Specify wound care protocols with dressing types and frequency 2
• Order regular skin assessments by nursing staff 2

Infection Control

• Document isolation precautions if applicable 2
• Include orders for outpatient parenteral antimicrobial therapy (OPAT) if needed, with specific administration instructions 2

Follow-up Care Planning

• Schedule follow-up appointments prior to discharge from SNF 1
• Identify healthcare providers who will manage specific conditions 1
• For diabetic patients, schedule outpatient follow-up within 1 month of discharge 1

Patient and Caregiver Education

• Document educational needs regarding diagnosis, medications, and monitoring 1
• Assess need for home health referral or outpatient education programs 1
• Identify appropriate caregivers to participate in educational sessions 1

Transitional Care Documentation

• Include current meal plan and activity levels 2
• Document prior treatment regimen and self-care education 2
• Specify hydration status and previous episodes of hypoglycemia 2
• Ensure close communication between transferring and receiving care teams to reduce readmission rates, which can be reduced by 29.8% with proper medication reconciliation 4

Common Pitfalls to Avoid

• Medication discrepancies occur in 71.4% of SNF admissions, with cardiovascular agents, opioids, and neuropsychiatric medications being most commonly affected 3
• One-third of transition medication errors occur during medication administration, with dose omissions being most common 5
• Prescribing errors are less common but more likely to cause harm 5
• Failure to document cognitive status can lead to poor care transitions for patients with cognitive impairment 1
• Inadequate communication between hospital discharge summary and patient care referral forms accounts for 62% of medication discrepancies 3