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 pain assessment performed. The patient reports pain at [site] rated ___/10 on a [numeric/verbal/FACES] scale [or PAINAD score ___/10 by observation for a nonverbal patient], at or below the stated goal of ___/10; quality [aching/sharp/burning]; pattern [constant/intermittent], without new breakthrough pain. Function is at baseline — ambulation, activities of daily living, and sleep are not limited beyond baseline by pain. The analgesic regimen [around-the-clock and as-needed agents] is tolerated with no untreated adverse effects; bowel function is maintained on the opioid regimen and sedation is at an acceptable level. RN-level assessment was required to apply a validated scale appropriate to the patient, interpret pain in its functional context, evaluate the effectiveness and adverse effects of the analgesic regimen given the diagnosis of [______], and screen for opioid-related sedation, respiratory depression, and constipation. Skilled nursing reinforced the regimen, the bowel and safety plan, and the symptoms requiring a call, and will continue monitoring pain and function. Continued skilled observation and assessment indicated. |
|---|
Select only the elements actually assessed and applicable; use the observational scale (for example PAINAD) for nonverbal or advanced-dementia patients and the self-report scale otherwise. Functional impact, adverse-effect screening, and the pain goal are charted when assessed and relevant to the regimen and diagnosis.
Short form
Skilled pain assessment: {site} pain ___/10 [scale] at/below goal ___; quality {...}; pattern {...}; function at baseline; regimen tolerated, no untreated adverse effects; bowel/sedation acceptable on opioid. RN judgment applied to apply a validated scale, evaluate the regimen, and screen adverse effects given {dx}. Continued skilled monitoring indicated. |
|---|