Safety assessment and mitigation qualify as skilled nursing under the Medicare coverage categories below. The note must connect skilled need to the diagnosis and the specific risk; management and evaluation of the plan of care is frequently the operative category.
Observation and assessment
The patient's safety status has a reasonable potential for change requiring skilled observation to identify the need to modify the plan. Recognizing a fall-risk profile, an environmental hazard, or a medication-safety problem and judging its significance require nursing judgment.
Teaching and training
Fall-prevention, safe medication management, and emergency procedures require skilled instruction with reinforcement to mastery.
Management and evaluation of the plan of care
When the patient's overall condition and the complexity of the unskilled services — personal care, equipment, and the home environment — require a registered nurse to coordinate them and ensure safety, management and evaluation of the plan of care is itself a skilled service.
Skilled procedures
For example, setting up and validating a medication-management or emergency-response system where performed.
