6. Mode A — complete chartable narrative
Use when the system is unremarkable or at baseline. Fill the bracketed blanks with the visit's actual values; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled-rationale portion supports defensibility when it is accurate, individualized, consistent with the plan of care, and tied to the findings, diagnosis, risks, interventions, and patient response documented during the actual visit.
Mode A — structured narrative example · edit to the actual visit Skilled psychiatric and mental-health assessment performed. Mood and affect are at the patient's baseline with a [negative / low] depression screen (PHQ-[2/9] score ___), and anxiety is at baseline with a [negative / low] screen (GAD-7 score ___). The patient denies thoughts of self-harm and of harm to others. There are no psychotic or manic symptoms and no severe agitation, and no substance-use concern is identified. The psychiatric condition, where present, is stable on treatment with reported adherence and tolerable side effects, and function, engagement, and safety are at baseline. RN-level assessment was required to screen mood and anxiety with validated tools, screen for risk of harm to self and others, distinguish a primary psychiatric presentation from a medical or delirium cause, and evaluate treatment adherence and the safety implications given the diagnosis of [______]. Skilled nursing reinforced coping strategies, treatment adherence, crisis resources, and the symptoms requiring a call, and will continue monitoring mental-health status. Continued skilled observation and assessment indicated. |
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Select only the elements actually assessed and applicable; cognition and delirium are documented in Cognitive / Mental Status and psychosocial stressors in Psychosocial / Caregiver. The validated screens and the risk screen are charted as performed and aligned with the OASIS-E2 mood items where applicable. Any identified risk to self or others is documented with the immediate safety response taken.
Short form
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 and safety at baseline. RN judgment applied to screen mood/anxiety/risk and distinguish a medical cause given {dx}. Continued skilled monitoring indicated. |
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