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Section Navigation Part 14 of 26 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. 7. Mode B — guided documentation prompts 10. Subjective — ask 11. Objective — observe 12. Measure 13. 8. Interventions performed 14. 9. Patient and caregiver teaching 15. 10. Response and reassessment 16. 11. Physician or provider notification 17. 12. Red flags and emergency escalation 18. 13. Skilled-need justification 19. 14. Medical-necessity statement 20. 15. Homebound relevance 21. 16. Weak vs. strong documentation 22. 17. Common audit and denial risks 23. Smart phrases 24. Normal narrative bank — stable / at-baseline 25. Abnormal narrative bank — focused / at-risk 26. 19. Sources and clinical references Previous Next 9. Patient and caregiver teaching Document each teaching point with topic, method, audience, and measured mastery (teach-back percentage or return-demonstration result), per Foundations — Teach-back and return demonstration.
Safe transfer and mobility techniques for the patient and caregiver, with return demonstration. Correct use of durable medical equipment and assistive devices. Energy conservation and task adaptation to preserve independence. Fall-prevention during activities of daily living (detail in Safety). Recognizing and reporting a functional change or a new inability to perform a task. Section Navigation Part 14 of 26 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. 7. Mode B — guided documentation prompts 10. Subjective — ask 11. Objective — observe 12. Measure 13. 8. Interventions performed 14. 9. Patient and caregiver teaching 15. 10. Response and reassessment 16. 11. Physician or provider notification 17. 12. Red flags and emergency escalation 18. 13. Skilled-need justification 19. 14. Medical-necessity statement 20. 15. Homebound relevance 21. 16. Weak vs. strong documentation 22. 17. Common audit and denial risks 23. Smart phrases 24. Normal narrative bank — stable / at-baseline 25. Abnormal narrative bank — focused / at-risk 26. 19. Sources and clinical references Previous Next 