For directors of nursing
Coverage that fits the way your floor already runs
A standing rounding day, a referral process that takes a minute, and a note in the chart the same day. Nothing about this should create a new task for your charge nurses.
How it works on the unit
| Step | What it looks like |
|---|---|
| Referral | A name and a reason — refused therapy, uncontrolled pain, new weakness, a contracture, a resident nobody can position comfortably. No form to chase. |
| The round | A standing day each week, agreed with you. New consults between rounds are seen as clinical urgency requires rather than held to the next visit. |
| The handoff | The clinician talks to the charge nurse and to therapy before leaving: what changed, what to watch for, and what to call about. |
| The note | Same-day, specific, and written so nursing, therapy and MDS can all use it. See the documentation standard. |
| Between visits | Direct access to the clinician who saw the resident, not a call center, including for medication questions and family conversations. |
Working with your rehab team
Most physiatry referrals in a skilled nursing facility exist because a resident cannot participate in therapy. Plans are built with that as the endpoint: pain controlled enough to tolerate a session, positioning and contracture risk addressed, and realistic rehabilitation potential stated plainly so therapy is not chasing a goal the body will not reach.
Request an intro callWritten and clinically reviewed by Raj Desai, MD, Medical Director · Updated