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 nutritional assessment performed. The patient is following the prescribed [diet] and reports intake adequate to meet needs with appetite at baseline; weight is ___ lb, [stable / within ___ lb of] baseline or goal, with no significant unintentional change on the trend. No malnutrition-risk indicators are present — no muscle wasting and no decline in intake. Chewing and swallowing are adequate for the prescribed diet. [Enteral nutrition, when present: the patient tolerates the ordered formula at the ordered rate, the site is intact and clean, and there is no elevated residual.] No GI symptoms are limiting intake. RN-level assessment was required to evaluate intake adequacy and therapeutic-diet adherence, screen for malnutrition risk against the weight trend, and manage and monitor enteral nutrition where present, given the diagnosis of [______] and its nutritional demands. Skilled nursing reinforced the therapeutic diet and the warning signs of declining intake requiring a call, and will continue monitoring nutritional status. Continued skilled observation and assessment indicated. |
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Select only the elements actually assessed and applicable; the enteral-nutrition components are charted only for patients on tube feeding, and swallowing mechanics are documented in Taste / Swallowing. Malnutrition screening and the weight trend are charted when assessed and relevant to the diagnosis and risk.
Short form
Skilled nutrition assessment: following {diet}, intake adequate, appetite at baseline; weight {###} lb stable vs goal, no malnutrition indicators; chewing/swallowing adequate; [enteral tolerated, site intact]; no GI symptoms limiting intake. RN judgment applied to evaluate intake and diet adherence and screen malnutrition risk given {dx}. Continued skilled monitoring indicated. |
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