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 skin assessment performed. The skin is intact with appropriate color, temperature, and moisture; a full inspection including the sacrum, heels, and skin folds found no pressure injury and no non-blanchable erythema at the pressure points, and no moisture-associated skin damage or concerning rash. The Braden Scale score is ___, indicating [low / at] risk; [where elevated: prevention is in place — a repositioning schedule, a pressure-redistribution surface, heel offloading, and skin protection]. There is no existing wound. RN-level assessment was required to perform the full skin inspection, score pressure-injury risk with the Braden Scale, distinguish blanchable from non-blanchable erythema at the pressure points, and institute or verify prevention given the diagnosis of [______] and the risk factors of immobility, incontinence, and nutrition. Skilled nursing reinforced pressure-injury prevention and skin protection and the changes requiring a call, and will continue monitoring skin integrity. Continued skilled observation and assessment indicated. |
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Select only the components actually assessed and applicable; the staging and treatment of any existing wound or pressure injury are documented in the Wounds / Pressure Injury reference, turgor with Hydration, and circulation-related changes with Peripheral Vascular. The Braden score and the pressure-point inspection are charted as performed and relevant to the diagnosis and risk.
Short form
Skilled skin assessment: skin intact, appropriate color/temp/moisture; full inspection incl. sacrum/heels — no pressure injury, no non-blanchable erythema; no moisture damage or concerning rash; Braden {score} ({risk}); [prevention in place]; no existing wound. RN judgment applied to score PI risk and institute prevention given {dx}. Continued skilled monitoring indicated. |
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