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not documented? not done! documenting professional rehabilitation nursing care


Level: Beginner-Intermediate

Contact Hours: Contact hours are no longer offered for this course.


Documentation Course Cover Graphic

Pricing and Licensure

Single User License: $49Order Your Copy Today

Single Unit License: $345

  • A unit license covers all staff of a single inpatient unit of 0-30 Beds for the life of the course.

Unit, multi-unit and facility pricing/licensure is determined by number of beds. Contact us if your unit has more than 30 beds or if you are interested in multi-unit or facility pricing. For more information on licensure, go to


Course Description

Rehab Nursing Series Course 4

Focus: Rehabilitation Documentation Requirements

This course is designed to continue the orientation of the new rehab nurse by developing documentation skills to prove that care is provided by a professional rehabilitation nurse, supporting the transition from med-surg-oriented documentation to rehabilitation-nursing-oriented documentation. Experienced rehab nurses will find the course helpful in refining documentation skills.

The course reviews the complexity of documentation requirements for rehabilitation settings and provides a framework for demonstrating the expertise of the professional rehabilitation nurse in daily documentation.


Course Chapters

Chapter 1 Overview

While med-surg skills are required of a rehabilitation nurse, the expertise of the professional rehabilitation nurse is proven in the record by evidence of compliance to regulatory, accreditation, and professional organization standards of care.

  • Is there a method to the madness of all the required elements of documentation?

  • What is the impact of the electronic health record on the ability to prove the expertise of the rehabilitation nursing professional in your documentation?

Chapter 2 CMS Regulations

This chapter focuses on the regulatory requirements for IRF's with an emphasis on documentation requirements. (This chapter is excluded from the Pediatric edition of this course.)

  • What is all the fuss about CMS regulations?

  • Why do the details count so much?

  • What is the importance of accurate FIM® scoring and the documentation that provides the evidence to support the number scored?.

Chapter 3 Rehab Nursing Standards

A brief review of CARF accreditation standards and rehabilitation nursing professional standards are included in this chapter.

  • Do you remember that your documentation demonstrates compliance to standards of care?

  • Do you know what is expected of the professional rehabilitation nurse?

Chapter 4 Documenting Professional Rehabilitation Nursing Care

It is not assumed that a patient is automatically receiving professional rehabilitation nursing care because they are under your care. The evidence is in the documentation.

  • How does rehabilitation nursing documentation look different from med-surg documentation?

  • How do you incorporate specific documentation strategies into your habits to demonstrate your rehabilitation nursing expertise in the record?

  • How do you apply these strategies to the documentation system you are required to use?

Chapter 5 Posttest


Learning Outcomes:

As a result of participating in this activity, the learner will be able to pass the posttest with a score of 80% or better, demonstrating knowledge of:

  • The elements of documentation that describe skilled professional rehabilitation nursing care.

  • The use of documentation principles to tell the story of the patient, describing therapeutic care activities, efforts to support goal achievement, coordination of care, and effectiveness in reducing the burden of care.

  • Key components of documentation that demonstrate the need, according to CMS law, for acute inpatient rehabilitation care.

Contact hours no longer will be provided for this course after October 1, 2019.If you would like to provide contact hours for this course at your site, contact us at for the details of the Mergener formula.

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