Skilled Nursing Goals
True or False: "Patient will understand their medications" is an appropriate goal. (If false- rewrite it to be true.)
What is FALSE: It must be measurable.
True or False: A patient's desire for therapy is enough to establish medical necessity.
What is FALSE- services must require skilled intervention.
Skilled care is needed when the patient requires _____.
What is the skills of a nurse or therapist that cannot be safely provided by non-skilled personnel.
At the end of a cert period, when should a patient be recertified?
What is when a patient continues to require skilled care, goals remain unmet or need updating, and medical necessity is documented.
To qualify for home health, a patient must show this status, meaning leaving the home is a taxing effort.
What is homebound?
Write a measurable SN goal for wound care.
What is...
Example: Patient/caregiver will demonstrate correct wound dressing change technique 3/3 times by discharge.
Why is the word, "maintain" risky in therapy goals?
What is it's vague and does not show measurable progress unless tied to preventing decline.
Which of these is NOT skilled?
a. Teaching new insulin injections
b. Re-teaching meds patient has been on for 10 years and fully understands
What is B?
True or False: A patient can be recertified if there has been no progress at all.
What is FALSE- lack of progress without documented skilled interventions, barriers, or complications does not justify recertification.
Which part of "SMART" goals is missing from this: "Patient will improve medication compliance"?
BONUS (10pts) Re-write the goal to include the above.
Rewrite this weak goal: "Patient will improve balance."
What is - Patient will stand unsupported for 2 minutes while preforming grooming tasks by 10/31/25 to reduce fall risk and increase independence.
Documentation must always connect interventions to this- ______
What is the diagnosis?
Give an example of a valid reason for recertification.
What is ____
Example: Pt with COPD continues to require skilled teaching and monitoring for O2 safety due to frequent desaturation episodes.
a. Patient will have community resources.
b. Patient will obtain food assistance within 30 days to improve nutrition and support CHF management.
What is B? It is specific, measurable, and tied to diagnosis/health.