How CascadeMD Transformed Skilled Nursing Documentation at our New Jersey Facility

Facility: Skilled Nursing
Role: Michelle Larson, Director of Nursing
Location: Northern New Jersey
Staff Impacted: 18 Nursing Team Members
Primary Use Case: Skilled Nursing Notes
EHR: PointClickCare

Background

At our Skilled Nursing Facility, ensuring the quality and consistency of clinical documentation is not just a best practice, it’s a requirement. As a skilled nursing facility serving a high-acuity population, our clinical records are central to care planning, reimbursement, audits, and surveys.

For years, one of our most persistent pain points was the skilled note, the clinical documentation nurses complete to support the medical necessity of continued skilled care. With 18 nurses on staff, rotating through three shifts, our documentation varied significantly depending on who was charting, when the note was entered, and whether the nurse had access to a workstation at the time.

While our staff were committed and diligent, the tools we had were slowing them down. Nurses often had to wait for unit carts to free up before entering notes. Some would jot down notes manually throughout their shift and enter them later, which created accuracy issues. Others would try to remember details from earlier in the day and complete their notes at the end of shift, sometimes hours after the patient interaction. Unsurprisingly, inconsistencies developed in note structure, phrasing, and completeness. We were spending more time reviewing documentation than delivering care.

The Documentation Challenge

As the Director of Nursing, I was concerned about the operational risks this created. Our challenges were clear:

• Inconsistent language and phrasing between nurses, despite corporate standards
• Missed documentation elements, such as clinical justification or measurable progress
• Delays in note entry due to limited workstation availability (unit carts)
• Manual and inefficient workflows that frustrated staff and delayed team collaboration
• Compliance concerns during audits and surveys due to documentation variability

Additionally, many of our nurses expressed discomfort typing lengthy notes or locating structured templates within the EHR. Even with training, documentation remained a time-consuming and error-prone task.

Partnering with CascadeMD

We decided to implement CascadeMD to improve our skilled note workflow and bring consistency, automation, and structure to our documentation process. What impressed me immediately about CascadeMD was that it didn’t just offer dictation, it allowed us to fully redesign how notes were created, while seamlessly integrating into our existing EHR, PointClickCare.

The CascadeMD team worked closely with our clinical leadership and corporate compliance team to build a custom Skilled Note Template that aligned with our exact documentation standards. This included:

• Predefined, organization-approved language built into each section of the note (admission reason, interventions, patient response, goals, etc.)
• Smart logic and required fields, ensuring that no note could be submitted until all necessary components were completed
• Conditional prompts, guiding nurses to provide appropriate clinical context without relying on memory or outside resources
• A voice-driven workflow, allowing nurses to simply dictate into the app, review the note, and submit it to PointClickCare in one streamlined process

To address staff concerns about using personal phones for documentation, CascadeMD provided dedicated handheld mobile devices, which we assigned by shift. This not only ensured privacy and data security, but gave every nurse real-time access to the tool without waiting for a cart or competing for a workstation.

Implementation Experience

Deployment was fast and well-supported. CascadeMD configured user accounts, loaded our patient census from PointClickCare, and trained our team on how to use the mobile and desktop app. Within one week, we had skilled note templates live and in use across all shifts.

Training uptake was strong because the process was intuitive. Nurses were able to:

1. Select the patient from a live census list
2. Open the Skilled Note template
3. Dictate or type their responses as prompted
4. Review and submit the note directly into the EHR

Because CascadeMD enforced structure and completeness at every step, our QA workload dropped immediately. We no longer had to chase down missing documentation or try to interpret inconsistent clinical language.

Results

Additional benefits we’ve experienced include:

• Reduced late entries, notes are now completed in the moment, not hours later
• Improved staff satisfaction, nurses no longer feel documentation is a burden
• Time saved on QA reviews and internal audits
• Stronger alignment with corporate standards without needing constant retraining
• Better survey outcomes, thanks to structured, complete documentation every time

Administrator's Perspective

"CascadeMD didn’t just improve our skilled notes, it fixed them. Our nurses no longer waste time hunting down a cart or trying to remember what happened five hours ago. Every note is guided, structured, and compliant by design. We don’t worry about documentation quality anymore, we trust it. It’s streamlined our operations and strengthened our survey readiness across the board." — M Larson, Director of Nursing