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Section Navigation Part 23 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 Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — not duplicate — disease-overlay smart phrases.
.SAFE_NORMAL
Skilled safety assessment: fall risk {low/mitigated}, gait {steady/device}; home {no hazards/addressed}; meds stored safely, organized, reconciled, no high-risk errors; emergency prep adequate (phone, contacts, detectors, can summon help); no abuse/neglect indicators. RN judgment applied to screen and mitigate hazards given {dx}. Continued skilled monitoring indicated.
.SAFE_FALL
Fall hx {#/timeframe}; gait/balance {steady/unsteady}; orthostatic {pos/neg}; vision {ok/impaired}; footwear {appropriate/unsafe}; polypharmacy {#}; environment factors {...}; screen {low/elevated}.
.SAFE_HOME
Hazards by area: entry {...}; living {rugs/clutter/cords}; bedroom {...}; bathroom {grab bars/mat}; kitchen {...}; lighting {adequate/poor}; stairs/railings {...}; addressed {...}.
.SAFE_MEDS
Reconciled vs order; storage {safe/unsafe}; organization {system/none}; high-risk meds {#}; duplications {y/n}; expired {y/n}; flagged to provider {...}.
.SAFE_PREP
Phone {working}; contacts {posted}; smoke/CO detectors {functioning}; evacuation {able/plan}; oxygen safety {verified}; equipment backup {plan}; can summon help {y/n}.
.SAFE_TEACH
Reviewed {fall-prevention/med safety/emergency procedures/oxygen safety} with {pt/cg}; method {teach-back/return-demo}; mastery {##}%.
.SAFE_COORD
Provider notified at {time} re {fall/hazard/med error/abuse concern}; reported {content}; order received {PT/DME/plan}; {mandated report filed}; reassessment {when}.
.SAFE_NECESSITY
Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.
Section Navigation Part 23 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