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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, January 25, 2011 Posted in: Inpatient Rehab

Documentation of function is not just a therapy event or responsibility when a patient is being cared for in an Inpatient Rehabilitation Facility (IRF). A patient’s path to recovery is a collaborative effort, bringing physicians, nurses, therapists and the patient’s family together to re-establish a normal, functional lifestyle for the patient. The focus is also more intense than a SNF model of care.

An article published in Nursing Times states, “The therapist roles overlap with those of the nurse and should not be viewed as separate but as complementary to each other.” Translated into practice – it is the nurse’s responsibility to aid and document patient’s function and progress, exceeding the perceived expectations of standard, medical/surgical nursing. A rehabilitation nurse goes beyond the medical/surgical model and must embrace a role that comfortably wears the hat of ‘therapist’ in the 14-16 hours these disciplines are routinely absent. That defines 24/7 Rehabilitation Nursing as required by Federal Regulations standard of rehab care.

So, why do we care if nursing documentation doesn’t focus on functional recovery? We lose more than two-thirds of the patient’s identifiable recovery, outside the interdisciplinary record, which defends medical necessity and incorporates 24/7 rehabilitation nursing as a primary requirement for an IRF level of care.

Read the complete article here:

Definition Rehab Nursing