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 neurologic assessment performed. The patient is alert with mental status at baseline; the cranial-nerve screen is grossly intact — the face is symmetric, speech is clear, swallowing is intact, pupils are equal and reactive, and extraocular movements and visual fields are full. Motor strength is 5/5 and symmetric with no pronator drift and normal tone; sensation is grossly intact and coordination is intact; gait is steady with the [device]. A stroke screen (F.A.S.T. / BE-FAST) is negative, and there are no focal deficits — findings are at the patient's neurologic baseline. RN-level assessment was required to perform the systematic neurologic examination, screen for acute stroke and other focal deficits, and distinguish a stable baseline from an acute change given the diagnosis of [______] and the associated neurologic risk. Skilled nursing reinforced the stroke warning signs and the imperative to call 911 immediately, and will continue monitoring neurologic status. Continued skilled observation and assessment indicated. |
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Select only the components actually examined and applicable; detailed cognition is documented in Cognitive / Mental Status, detailed sensory mapping in Touch / Sensation, and gait and strength detail with Function and Musculoskeletal. The stroke screen and the baseline comparison are charted as performed and relevant to the diagnosis and risk.
Short form
Skilled neuro assessment: alert, mental status at baseline; CN grossly intact (face symmetric, speech clear, swallow intact, pupils equal/reactive, EOM/fields full); motor 5/5 symmetric, no drift, normal tone; sensation grossly intact; coordination intact; gait steady; stroke screen negative; no focal deficits. RN judgment applied to screen for stroke and detect acute change given {dx}. Continued skilled monitoring indicated. |
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