SNF Skilled Nursing Progress Note (Medicare Skilled Need)

Date/Time of Service: [Date and time of service]

Patient: [Name; DOB or MRN per facility policy]

Facility/Unit/Room: [Facility name, unit, room]

Author: [Name, credentials (RN/LPN/LVN)]

Visit Type: [Daily skilled visit / Change in condition / Wound care / Teaching-training / Medication management / IV therapy / Other]

Reason for Visit & Interval History

Skilled Trigger: [Explicit statement of why skilled nursing is required today]

Interval Events: [New orders, medication changes, condition changes, lab results, falls, or transfers since last skilled note; state "No interval changes" if none]

Subjective

[Patient-reported symptoms relevant to skilled needs; adherence issues; education feedback; patient goals] (If patient cannot report, state why and document alternate source.)

Objective

Vitals/Data: [Relevant vitals with units; weight trend; glucose values; oxygen device and saturation; I&O as applicable]

Focused Exam: [Pertinent findings tied to skilled reason—respiratory, cardiac, wound, neuro, etc.]

Wound/Device: [If wound or line care is performed: location, measurements, tissue type, drainage, periwound condition, dressing/products applied, tolerance; for lines: site assessment, patency, complications] (Omit if not applicable to today's visit.)

Skilled Services Performed

(Repeat this block for each skilled problem addressed; link to care plan goals.)

[Problem]: [Clinical problem and care plan goal—restore / maintain / prevent decline]

Skilled Rationale: [Why this requires skilled nursing—inherent complexity, clinical judgment required, patient-specific risks, or reasonable probability that findings will lead to treatment modification]

Intervention: [What was done; technique; materials/products; parameters monitored; education delivered if applicable]

Response: [Measurable patient response—pain score change, tolerance, teach-back accuracy, procedure tolerance]

Progress: [Trend vs. baseline or prior visit with metrics; for maintenance goals, document stability and risk mitigation]

Barriers/Communication: [Barriers to progress and mitigation efforts; provider/IDT notifications with resulting orders] (Include only if applicable.)

Assessment

[For each problem: current status (improving / stable / worsening) with supporting evidence; statement of why skilled nursing remains necessary]

Plan

Next Visit Focus: [Planned skilled services and rationale based on today's findings]

Monitoring Parameters: [Thresholds for escalation—vital signs, weight, wound changes, glucose, device complications as relevant to this patient]

Discharge Criteria: [Conditions indicating readiness for discharge from skilled nursing]

Pending: [Labs, consults, equipment, clarifications needed] (Omit if none.)

Signature: [Electronic signature per policy]

Date/Time Signed: [Date and time signed]

(Use concise documentation. For missing information, document why unavailable rather than leaving blank. Late entries or addenda must be labeled as such.)