Normal narrative bank — stable / at-baseline
Each shows what was assessed, the objective finding, the baseline comparison, functional or safety relevance, skilled judgment, and reinforcement — edit to the actual visit.
N1 Adequate support and capable caregiver | Skilled psychosocial and caregiver assessment completed. The support system is adequate for the patient's needs, and the primary caregiver — the patient's spouse — is competent, willing, and not showing significant strain on screening, providing reliable assistance with medications and meals. The patient is coping adequately, and the social determinants are stable with no unmet needs or financial barrier to the plan. Findings indicate an adequate psychosocial situation. RN-level assessment was required to evaluate the support system and caregiver capacity, screen for strain and social-determinant barriers, and confirm the plan's supports given the diagnosis. Caregiver support and respite resources reinforced; teach-back accurate. Continued skilled monitoring indicated. |
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N2 Caregiver supported, strain prevented | Skilled psychosocial assessment completed. The primary caregiver continues to provide competent care and reports manageable stress; with the respite and support resources previously arranged in use, a caregiver-strain screen remains negative. Social determinants are stable. Findings indicate sustained adequate support with strain prevented. RN-level assessment was required to re-screen caregiver strain, confirm the support resources are working, and reassess the social determinants. Caregiver coping and the available resources reinforced; teach-back accurate. Continued skilled monitoring indicated. |
N3 Resources coordinated, needs met | Skilled psychosocial assessment completed after prior resource coordination. The previously identified needs are now met — transportation to appointments and meal delivery are in place — and the patient reports stability; no new unmet needs or financial barriers. Findings indicate resolved needs with resources in place. RN-level assessment was required to confirm the coordinated resources are meeting needs and re-screen the social determinants. The resources and how to maintain them reinforced; teach-back accurate. Continued skilled monitoring indicated. |
N4 Coping well with adjustment support | Skilled psychosocial assessment completed for a patient adjusting to a new diagnosis. The patient is coping adequately, engaging the support system and using learned strategies, without signs of poor adjustment; the caregiver is capable and supportive and the social determinants are stable. Findings indicate adequate coping with support. RN-level assessment was required to evaluate coping and adjustment, confirm the support system, and screen the social determinants. Coping strategies and support resources reinforced; teach-back accurate. Continued skilled monitoring indicated. (Mood screened in the Psychiatric / Mental Health reference.) |
N5 Advance-care-planning addressed | Skilled psychosocial assessment completed with attention to advance-care-planning. The patient's goals of care and wishes have been discussed and documents are in place; the support system and caregiver are adequate and the social determinants stable. Findings indicate an adequate psychosocial situation with advance-care-planning addressed. RN-level assessment was required to evaluate supports, screen the social determinants, and confirm advance-care-planning status given the diagnosis. The plan, the documents, and support resources reinforced; teach-back accurate. Continued skilled monitoring indicated. |
N6 Interval psychosocial check, stable | Skilled psychosocial assessment completed at the scheduled interval visit. The support system, caregiver capacity, and social determinants are unchanged and adequate, the caregiver-strain screen remains negative, and there are no new unmet needs or barriers. Findings stable. RN-level assessment was required to confirm the psychosocial situation against baseline, re-screen caregiver strain and the social determinants, and reassess the plan's supports given the diagnosis. Caregiver support and resources reinforced; teach-back accurate. Continued skilled monitoring indicated. |