24-Hour Rehabilitation Nursing: The Proof Is in the Documentation

Authors

  • Pam Hentschke MSN RN CRRN

    Corresponding author
      phentschke@carolinas.org
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    • Pam Hentschke, MSN RN CRRN, is a clinical nurse specialist for Carolinas Rehabilitation in Charlotte, NC


phentschke@carolinas.org

Abstract

For a facility to be classified as an inpatient rehabilitation facility (IRF), Medicare requires that the facility provide 24-hour rehabilitation nursing. Documentation is important because it helps determine the most appropriate site for the provision of care. Functional assessments are ongoing and should provide information about patients and which interventions are most appropriate; this allows for successful achievement of rehabilitation goals. Nurses must define the elements of a quality assessment based on the individual patient and then monitor findings and respond appropriately. Reimbursement is supported by measuring functional outcomes based on the initial assessment of patients. The final reimbursement, based on possible denial of a claim, is supported by documentation of the functional outcome in the medical record. Medicare contractors cannot observe the everyday interventions nurses use with patients, so they require documentation as proof. This article features examples of documentation that nurses can use to help meet the expectation of 24-hour nursing. Following through with these suggestions will not only help provide proof of 24-hour nursing, more accurate reimbursement, and the security of a full reimbursement, but ultimately will ensure quality rehabilitation services and care for patients.

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