.PSY_NORMAL

Skilled psychiatric assessment: mood/affect at baseline, PHQ-{2/9} {score} {neg/low}; anxiety at baseline, GAD-7 {score}; denies thoughts of self-harm or harm to others; no psychosis/mania/agitation; treatment stable/adherent; function/safety at baseline. RN judgment applied to screen mood/anxiety/risk and exclude a medical cause given {dx}. Continued skilled monitoring indicated.

.PSY_MOOD

PHQ-{2/9} {score}; depressed mood {y/n}; anhedonia {y/n}; sleep {...}; appetite {...}; energy {...}; concentration {...}; GAD-7 {score}; worry/restlessness {...}; vs baseline {stable/worse}.

.PSY_RISK

Screened thoughts of self-harm/harm to others: {denies/present}; [if present: risk level {...}; not left alone; provider and {crisis/911} contacted; 988 provided; safety plan completed; means-access reduction per protocol].

.PSY_SYMPTOMS

Psychosis {hallucinations/delusions/none}; mania {y/n}; agitation {none/severe}; substance use {screen}; acute change {evaluate medical/delirium}.

.PSY_SKILL

Administered {PHQ/GAD-7}; assessed/responded to risk; evaluated medication adherence/side effects; supportive communication; coordinated {MH referral/crisis}; distinguished medical vs psychiatric.

.PSY_TEACH

Reviewed medication adherence/timeline/side effects, coping strategies, and crisis resources (988 Lifeline) with {pt/cg}; method {teach-back}; mastery {##}%.

.PSY_COORD

Provider notified at {time} re {risk/positive screen/symptoms}; reported {content}; order received {referral/evaluation}; {crisis resources provided}; reassessment {when}.

.PSY_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.