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Section Navigation Part 5 of 26 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. 7. Mode B — guided documentation prompts 10. Subjective — ask 11. Objective — observe 12. Measure 13. 8. Interventions performed 14. 9. Patient and caregiver teaching 15. 10. Response and reassessment 16. 11. Physician or provider notification 17. 12. Red flags and emergency escalation 18. 13. Skilled-need justification 19. 14. Medical-necessity statement 20. 15. Homebound relevance 21. 16. Weak vs. strong documentation 22. 17. Common audit and denial risks 23. Smart phrases 24. Normal narrative bank — stable / at-baseline 25. Abnormal narrative bank — focused / at-risk 26. 19. Sources and clinical references Previous Next Required data to chart Orientation · recent and remote memory · attention · executive function and judgment · level of consciousness · the acuity and course (acute/fluctuating vs chronic/progressive) · a validated screen result · the impact on safety, medication management, and capacity · comparison to baseline.
Section Navigation Part 5 of 26 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. 7. Mode B — guided documentation prompts 10. Subjective — ask 11. Objective — observe 12. Measure 13. 8. Interventions performed 14. 9. Patient and caregiver teaching 15. 10. Response and reassessment 16. 11. Physician or provider notification 17. 12. Red flags and emergency escalation 18. 13. Skilled-need justification 19. 14. Medical-necessity statement 20. 15. Homebound relevance 21. 16. Weak vs. strong documentation 22. 17. Common audit and denial risks 23. Smart phrases 24. Normal narrative bank — stable / at-baseline 25. Abnormal narrative bank — focused / at-risk 26. 19. Sources and clinical references Previous Next 