6. Mode A — complete chartable narrative
Use when the perineal and genital skin is intact or healing, the barrier plan is effective, and there is no infection. Fill the bracketed blanks with the visit’s actual findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled external genital and perineal skin assessment completed with the patient’s consent and privacy and a chaperone present per policy. The perineal and genital skin is intact without erythema, denudation, or breakdown; [no incontinence-associated dermatitis / known dermatitis improving with the barrier protocol]. [Perineal wound healing on trajectory — see Wounds.] The catheter/device entry-site skin is intact without erythema or trauma. No signs of a necrotizing or fungal infection; moisture controlled with an effective barrier and containment plan. The assessment against baseline, including the distinction of dermatitis from pressure injury and the surveillance for necrotizing infection, confirms intact or healing skin and continued appropriateness of the plan; perineal skin care, barrier application, and the warning signs to report were reinforced with the patient/caregiver, who [teach-back result] (cross-reference Wounds, Urinary/Renal). |
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Short form
Skilled perineal/genital skin assessment (consent, privacy, chaperone per policy): skin intact, no dermatitis or breakdown; [wound healing]; device entry-site intact; no necrotizing/fungal infection; barrier effective. Plan continued. Skin-care/barrier teaching reinforced, teach-back correct (see Wounds). |
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