N2

Chronic dementia at baseline, no acute change

Skilled cognitive assessment completed for a patient with chronic dementia. The patient is oriented to person and intermittently to place, with impaired recent memory consistent with the established baseline; attention is variable but unchanged, and the level of consciousness is stable with no fluctuation — no acute change and a negative delirium screen. Cognition limits independent medication management, which is supervised. Findings indicate dementia at baseline without acute change. RN-level assessment was required to confirm the chronic baseline, exclude superimposed delirium, and reassess the safety plan. The caregiver was reinforced on routine, reorientation, and recognizing an acute change; teach-back accurate. Continued skilled monitoring indicated.

N3

Delirium resolved, returned to baseline

Skilled cognitive assessment completed after a prior delirium episode. The patient has returned to the cognitive baseline — oriented and attentive as before, with a stable level of consciousness and a negative CAM — following treatment of the precipitating cause. Findings reflect resolution of the prior delirium with a return to baseline. RN-level assessment was required to confirm resolution against the prior acute change and screen for recurrence. The caregiver was reinforced on recognizing delirium and reporting an acute change promptly; teach-back accurate. Continued skilled monitoring indicated.

N4

Cognition supports medication management

Skilled cognitive assessment completed with a focus on medication safety. Orientation, recent memory, attention, and executive function are at baseline, and the patient correctly described and demonstrated the medication routine; the level of consciousness is stable with no delirium features. Findings indicate cognition adequate for safe medication self-management. RN-level assessment was required to evaluate the cognitive capacity for medication management and screen for change. The regimen, the system, and the changes to report reinforced; teach-back accurate. Continued skilled monitoring indicated. (Medication-management function in the Function reference.)

N5

Mild impairment, compensated with support

Skilled cognitive assessment found mild cognitive impairment at the established baseline — mild recent-memory difficulty on the Mini-Cog without disorientation or inattention — compensated by caregiver support and reminder systems; the level of consciousness is stable with no acute change. Findings indicate stable mild impairment compensated with support. RN-level assessment was required to characterize the impairment, confirm it is unchanged, and verify the support compensates for it. The caregiver was reinforced on reminders, routine, and recognizing decline; teach-back accurate. Continued skilled monitoring indicated.

N6

Interval cognitive check, no change

Skilled cognitive assessment completed at the scheduled interval visit. Orientation, memory, attention, and executive function are unchanged from baseline, the level of consciousness is stable, and there is no acute change or fluctuation — a negative delirium screen. Cognition continues to support the current plan for safety and medication management. Findings stable. RN-level assessment was required to confirm cognition against baseline, screen for an interval acute change, and reassess the safety implications given the diagnosis. Supportive strategies and the changes to report reinforced; teach-back accurate. Continued skilled monitoring indicated.