Skilled Nursing Facility – Acute Rehab Follow-Up Progress Note Template

Chief Complaint

Skilled Nursing Facility – Acute Rehab Follow-Up Progress Note Template

DETAILED CHIEF COMPLAINT

[Describe the reason for the visit, including ongoing skilled medical management and rehabilitation oversight. Include details about recent hospitalization, functional decline, and the medical necessity of the visit due to active medical comorbidities, medication management needs, and skilled therapy participation. add in medical conditions in assessment and plan]

Patient Overview

[Provide an overview of the resident's current status, including their participation in skilled therapy, ability to communicate needs, and any acute distress noted during evaluation.]

Interval History

[Summarize changes since the last evaluation, including nursing staff reports, therapy progress, and any symptoms or lack thereof (e.g., chest pain, shortness of breath, dizziness, syncope, or neurologic deficits).][ add personalization information from encounter transcript to add indiviualization of note]

Nursing / Therapy Review

[Document review of nursing notes, therapy documentation, vitals, medication administration records, and recent labs. Include therapy reports on the resident's need for skilled intervention and areas of impairment (e.g., strength, balance, endurance, safety awareness).]

Vital Signs

[Document vital signs and note if they are within acceptable parameters or if any abnormalities are present.]

lab results

[ reviewed results will continue to monitor][add results provided in visit context]

Physical Examination

General: [Describe general appearance, e.g., awake, alert, no acute distress.] Cardiovascular: [Describe findings, e.g., regular rate and rhythm, no acute edema.] Respiratory: [Describe findings, e.g., clear to auscultation, non-labored respirations.] Neurologic: [Describe findings, e.g., no acute focal deficits, chronic findings unchanged.] Musculoskeletal: [Describe findings, e.g., generalized weakness and reduced endurance.] Skin: [Describe findings, e.g., intact, no acute breakdown noted.]

FUNCTIONAL / REHABILITATION STATUS

Mobility: [Describe mobility status, e.g., requires assistive device and staff assistance.] Transfers: [Specify level of assistance required, e.g., one-person / two-person assist.] ADLs: [Describe level of assistance required for activities of daily living, e.g., partial to extensive assistance.] Therapy Services: [List ongoing therapy services, e.g., skilled PT / OT (± ST).] [Include a statement about the resident's inability to safely perform functional tasks independently and the risk for decline without skilled intervention.]

ASSESSMENT & PLAN

[List each diagnosis with associated plan, medications, and monitoring parameters. Use the following structure for each diagnosis:][List each problem and number and separate, with active management and risk awareness. link medication and doses to each problem add education and monitoring applicable to each plan of care do not include ICD 10 codes][Assessment: Brief status statement (stable / improving / uncontrolled / high-risk). Reference pertinent vitals, labs, symptoms, or recent events. Indicate why ongoing medical management is required in SNF/LTC. 1. [Diagnosis Name] [Provide a brief description of the diagnosis and contributing factors.] Plan: [Outline the treatment plan, including therapy, monitoring, and any specific interventions.] Medications: [List medications with dosage and frequency.] Monitoring: [List monitoring parameters, e.g., therapy tolerance, pain control, blood pressure trends, etc.]

MEDICAL NECESSITY & MDM STATEMENT

[Summarize the resident's medical complexity, active diagnoses, and the necessity of provider-level assessment, medication management, and monitoring. Include a statement about the complexity of conditions and medication management supporting moderate-to-high complexity MDM .]

Provider Signature

[Enter provider's name and NP.]