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 gastrointestinal assessment performed. The abdomen is soft, non-distended, and non-tender, with bowel sounds present and normoactive in all four quadrants and no masses, guarding, rigidity, or rebound. The bowel pattern is regular and at the patient's baseline, with the last bowel movement [today / within the usual interval] of normal consistency; there is no nausea or vomiting and no sign of GI bleeding. [An ostomy, where present: the stoma is beefy-red and viable, output is appropriate in volume and character, the appliance is sealed, and the peristomal skin is intact.] RN-level assessment was required to perform the abdominal examination, evaluate bowel function and screen for an acute abdomen and GI bleeding, and manage ostomy care where present, given the diagnosis of [______] and the medication regimen. Skilled nursing reinforced the bowel regimen and the warning signs of bleeding and an acute abdomen, and will continue monitoring GI status. Continued skilled observation and assessment indicated. |
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Select only the components actually examined and applicable; intake and diet are documented in Nutrition, fluid balance in Hydration, abdominal-pain characterization in Pain, and the ostomy device in Lines / Drains / Devices. The bowel and bleeding screens are charted as performed and relevant to the diagnosis and risk.
Short form
Skilled GI assessment: abdomen soft, non-distended, non-tender; bowel sounds normoactive ×4; no mass/guarding/rigidity/rebound; bowel pattern at baseline, last BM {when}; no nausea/vomiting; no bleeding signs; [ostomy stoma viable, output appropriate, skin intact]. RN judgment applied to screen for acute abdomen and bleeding and manage bowel/ostomy care given {dx}. Continued skilled monitoring indicated. |
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