A Nursing-Centered Standardized Operating Procedure for Transitional Neurorehabilitation After Stroke and Traumatic...

The goal of this protocol is to provide a reproducible nursing-centered standardized operating procedure (SOP) for transitional neurorehabilitation in adult patients recovering from stroke or traumatic brain injury. Post-discharge neurorehabilitation is often fragmented, and patients may experience reduced rehabilitation intensity, inconsistent home supervision, delayed recognition of safety risks, and increased caregiver pressure. This protocol organizes the discharge-to-home transition into a structured nursing workflow that includes pre-discharge risk stratification, caregiver skill training with teach-back verification, individualized home rehabilitation planning, tier-linked follow-up, adherence documentation, safety surveillance, and predefined escalation rules. The procedure is designed to help nurses translate broad rehabilitation principles into repeatable actions that can be documented, audited, and adapted to different patient risk levels. A prospective clinical application involving 121 patient-caregiver dyads was used to demonstrate how the SOP can be implemented, monitored, and evaluated over a 6-month home rehabilitation period. Representative outcomes include completion of baseline risk tiering, caregiver competency verification, follow-up delivery, adherence recording for home rehabilitation, safety event documentation, and closed-loop escalation management. This protocol provides a practical framework for strengthening continuity of nursing care after discharge and for standardizing key rehabilitation support tasks across the hospital-to-home transition.