What should be included in a skilled nursing (SN) follow-up note for a provider?

Skilled Nursing Follow-Up Note for Provider

A skilled nursing follow-up note must include comprehensive clinical data, course of illness and treatment, goals of care, medication reconciliation with titration plans, and a specific follow-up care plan with scheduled appointments within 7 days of discharge. 1, 2

Essential Clinical Data to Document

• Vital signs (blood pressure, heart rate, respiratory rate, pulse oximetry, temperature) 1
• Laboratory values including BUN, creatinine, potassium, sodium, and hematocrit 1
• Weight trajectory with indication of volume status and any volume treatment administered 1
• Physical assessment findings including presence/absence of edema, jugular venous pressure, lung sounds, and circulation to extremities 1
• Functional status including mobility, activities of daily living (ADL), and cognitive status 1, 2

Course of Illness and Treatment Response

• Important decisions and events during the SNF stay, including response to therapy or lack of response 1
• Adverse events or adverse drug reactions that occurred during the stay 1
• Changes in patient cognition (dementia/delirium episodes) 1
• Deviations from chronic home management and the rationale for these changes 1
• Precipitating factors for any acute changes in condition, such as infections, arrhythmias, or metabolic disturbances 1, 3

Medication Management Documentation

• Complete medication list with current doses, including guideline-directed medications 1, 4
• Medication changes with clear rationale documented, especially if not on standard guideline therapy 1
• Medication sensitivities and adverse reactions (e.g., hyperkalemia from spironolactone) 1
• Titration plan with target parameters for blood pressure, heart rate, and weight 1, 4
• Response to diuretic agents and current volume status 1

Goals of Care and Management Plan

• Target parameters for weight, heart rate, and blood pressure 1, 4
• Identification of who will manage ongoing care (cardiology follow-up, primary care, or SNF physician) 1
• Risk assessment for rehospitalization with specific monitoring parameters 1, 2
• Drug titration goals for the next 30 days after transition 1
• Advance care preferences including resuscitation status and hospital transfer preferences 1, 4

Patient and Family Education Status

• Documentation of education delivered regarding disease management, medication instructions, and self-monitoring 1
• Patient and family knowledge and acceptance of the care plan 1
• Assessment of self-management capacity including cognition, health literacy, depression, and anxiety 1, 4
• Family support capacity and their understanding of the care plan 1, 4
• Instructions on when to notify healthcare providers (weight gain >2-3 lbs in 24 hours, edema, shortness of breath, mental status changes) 1, 2

Follow-Up Care Plan

• Scheduled follow-up appointment within 7 days of SNF discharge with the patient's primary or specialty provider 1, 2
• Specific timeframe for follow-up with identification of issues requiring monitoring before next visit 5
• Referrals to specialists or home health services if needed for ongoing management 1, 2, 4
• Assessment of need for home health care based on self-management capabilities 1, 2

Condition-Specific Documentation

For Heart Failure Patients:

• Ejection fraction, NYHA functional class, echocardiogram results, type of HF, and HF pathogenesis 1
• Signs and symptoms of fluid retention (edema, abnormal lung sounds, cough, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, jugular vein distension) 1
• Implantable device information (pacemakers, cardiac resynchronization therapy, ICDs) with device function status 1

For Stroke Patients:

• Formal assessment of mobility, ADL, and communication/cognition scheduled within 30 days 2
• Caregiver support needs and education provided 2

Common Pitfalls to Avoid

• Inadequate bidirectional communication between facilities leads to adverse events, increased costs, and increased length of stay 1, 2
• Missing the 7-day follow-up appointment results in care gaps and potential readmissions 1, 2
• Incomplete medication reconciliation can cause adverse drug events and therapeutic failures 1, 4
• Failure to document target parameters (weight, blood pressure, heart rate) leaves receiving providers without clear management goals 1, 4
• Insufficient assessment of self-management capacity may result in unsafe discharge planning 1, 4