N2

Independent with appropriate device

Skilled functional assessment completed. The patient is independent in activities of daily living and manages instrumental activities independently, including medication management with an established system; transfers and ambulation are independent with a cane, performed safely with a steady gait. No functional decline from baseline. The cane is appropriately sized, in good condition, and used correctly. Findings indicate independent function at baseline. RN-level assessment was required to confirm independent function, assess device fit and use, and screen for decline given the diagnosis. Energy conservation and the warning signs of decline reinforced; teach-back accurate. Continued skilled monitoring indicated.

N3

Improving function in recovery

Skilled functional assessment completed at the recovery visit. Function has improved from the prior visit — the patient now transfers with supervision rather than a one-person assist and ambulates a greater distance with the walker — reflecting progress with therapy. Instrumental activities are increasingly managed with reducing support. No safety concern with the observed transfers. Findings reflect functional improvement. RN-level assessment was required to evaluate the improving assistance level against the prior assessment, confirm transfer safety, and coordinate with the therapy plan. Safe technique, device use, and pacing reinforced; return demonstration accurate. Continued skilled monitoring indicated.

N4

Stable function with caregiver support

Skilled functional assessment completed. With caregiver assistance for bathing, dressing, and meals, the patient's activities of daily living are met at the established level and the home routine is maintained; transfers are performed safely with the caregiver's assistance and the appropriate device. No new decline. The caregiver demonstrated safe assistance technique. Findings indicate stable function with adequate support. RN-level assessment was required to confirm the support plan meets needs, evaluate transfer safety, and screen for change. The caregiver was reinforced on safe transfers and the changes requiring a call; return demonstration accurate. Continued skilled monitoring indicated.

N5

DME appropriate and correctly used

Skilled functional assessment completed with a focus on equipment. The durable medical equipment in use — a rolling walker, a raised toilet seat, and grab bars — is appropriate to the patient's needs, in good condition, and used correctly; transfers using the equipment are safe and the patient demonstrated correct sequencing. Activities of daily living are at baseline assistance. Findings indicate appropriate, correctly used equipment supporting safe function. RN-level assessment was required to evaluate equipment appropriateness and correct use and confirm safe transfers. Correct device use and maintenance reinforced; return demonstration accurate. Continued skilled monitoring indicated.

N6

Interval functional check, aligned to plan

Skilled functional assessment completed at the scheduled interval visit. Activities of daily living remain at the established level of assistance and instrumental activities are managed with the established support; transfers and gait are at baseline with the device and safe; no new decline. The findings align with the plan of care and the documented self-care and mobility items. Findings stable. RN-level assessment was required to confirm functional status against baseline and the plan, assess transfer safety, and screen for change given the diagnosis. Safe technique and warning signs reinforced; return demonstration accurate. Continued skilled monitoring indicated.