How This Service Works
Depending on the patient’s needs, physician or authorized practitioner orders, and payer authorization, skilled nursing may include nursing assessments, health-status monitoring, medication-related nursing services, wound or skin care, teaching, care coordination, and other nursing interventions within professional scope.
Nurses evaluate the patient’s response to care, communicate important findings, provide education to patients and caregivers, and coordinate with other members of the healthcare team when follow-up is needed.
Skilled nursing is individualized. The exact frequency, tasks, and goals should be based on clinical need, medical orders, applicable regulations, payer requirements, and the patient’s plan of care.
Common Components
- Nursing assessment
- Clinical monitoring
- Medication-related nursing care
- Wound and skin care when ordered
- Patient and caregiver education
- Care coordination and clinical communication
Planning, Documentation, and Coordination
Services should follow the applicable medical order, authorization, person-centered plan, plan of care, or service agreement. Staff document the support provided, communicate significant changes, and remain within the scope of the role for which they are trained and authorized.