During the admission process, registered nurses give the patient an in-depth assessment covering all systems in the body, medical history, and the present condition of the patient. Going beyond the admission assessment, nurses determine the patient’s baseline in performance based on cognitive and physical performance, and identifies goals.
Throughout a patient’s first day of in-home rehabilitation, the nurse is observing the patient to determine their level of ability in everyday tasks, including eating, bathing, and dressing. Nurses will use this information to put interventions in place for the patient as needed and to tailor their in-home rehabilitation for their specific needs.
For the duration of a patient’s time in in-home rehabilitation, nurses perform assessments to determine the patient’s progress and needs. During these assessments, nurses chart the patient’s medical condition and progress in rehabilitation. This information is used to assess the patient’s progress and determine any changes or addition to rehabilitation the patient might need. Nurses provide education to the patient and family/primary caregiver about their medication and disease education during their in-home rehabilitation appointments.
They encourage their patients to be as independent as possible and complete as many tasks as they can on their own. Nurses will put emphasis on educating the patient on their rehabilitation care plan to ensure that the patient can be independent when possible.
Discharge from in-home rehabilitation is different for everyone and a patient’s discharge from in-home rehabilitation largely depends on the nurse’s observations and assessment notes taken during visits to the home. Treatment goals are set with the patient and/or primary caregivers throughout treatment and on-going assessments by the nurse to see what progress the patient has made. Once all treatment goals are met, nurses will determine when a patient is discharged from in-home rehabilitation. Nurses will continue to monitor and educate the patient until discharge is deemed appropriate.