Assessments & care plans in Skilled Nursing Facilities

What's an assessment?

When you go to a Skilled Nursing Facility (SNF), a team from different medical fields plans your care. Your SNF care is based on your health needs, your doctor's orders, and information the team gathers when they do periodic assessments of your condition. Your doctor and the SNF team (with your input) use the assessments to set your health goals  and decide what services you need.

Medicare requires your SNF to record and submit some of your assessments, including one that usually happens within the first 5 days of your SNF stay. This is known as the “5-day assessment.” Medicare also requires the SNF to do an assessment when your Part A SNF coverage ends, even if you’re going to stay in the SNF facility. This is known as “the Part A discharge assessment.” SNFs may also choose to do other optional assessments during your stay.

What does an assessment include?

What's a care plan?

After assessing your health condition, SNF staff prepare or update your care plan. You (if you're able), your family, or someone acting on your behalf can help plan your care. Let the staff know if you want to be involved in planning your care. Staying involved keeps you aware of the care you’re getting and your progress toward reaching your health goals.

What does a SNF care plan include?