.COG_NORMAL

Skilled cognitive assessment: A&O ×{3/4} at baseline; memory/attention/executive function at baseline; stable LOC, no delirium features; validated screen at baseline; cognition supports safe function/med management; no new change. RN judgment applied to screen for delirium and judge safety/capacity given {dx}. Continued skilled monitoring indicated.

.COG_ASSESS

Orientation {person/place/time/situation}; recent memory {intact/impaired}; remote {intact/impaired}; attention {intact/inattentive}; executive/judgment {intact/impaired}; LOC {alert/fluctuating}; course {acute/chronic}.

.COG_DELIRIUM

CAM: acute onset/fluctuating {y/n}; inattention {y/n}; disorganized thinking {y/n}; altered LOC {y/n}; CAM {pos/neg}; possible precipitant {infection/meds/metabolic/dehydration/hypoxia/pain}.

.COG_SKILL

Administered {Mini-Cog/MoCA/CAM}; compared to baseline; screened delirium and {escalated/ruled out}; reorientation strategies; adapted med safety; coordinated {evaluation/referral}; capacity/safety addressed.

.COG_TEACH

Reviewed reorientation, routine, delirium recognition, and medication supervision with {caregiver}; method {teach-back}; mastery {##}%.

.COG_COORD

Provider notified at {time} re {acute change/delirium/safety}; reported {content}; order received {evaluation/labs}; reassessment {when}.

.COG_SAFETY

Call for an acute change in mental status, new confusion, or a fluctuating level of consciousness; 911 for a severely altered/declining LOC or new focal neuro signs.

.COG_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.