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 respiratory assessment performed. Respiratory rate ___ and unlabored with a regular pattern; lung fields clear to auscultation in all anterior, lateral, and posterior fields bilaterally. SpO2 ___% on room air [or ___ L oxygen per order, at the ordered target]. No accessory-muscle use, retractions, nasal flaring, or pursed-lip breathing; patient speaks in full sentences without dyspnea. Denies cough, sputum production, hemoptysis, or pleuritic chest pain. Chest expansion symmetric; no cyanosis or digital clubbing. Respiratory status stable from baseline. RN-level assessment was required to detect early signs of pulmonary decompensation given the diagnosis of [______], to evaluate the response to the ordered respiratory regimen [bronchodilators, inhaled corticosteroids, oxygen, nebulizer], and to identify medication-related pulmonary effects such as ACE-inhibitor cough, opioid-related hypoventilation, or beta-blocker-associated bronchospasm. Skilled nursing reinforced the symptoms and oxygen-saturation thresholds requiring immediate reporting and will continue monitoring for changes associated with the patient's pulmonary diagnosis and medication regimen. Continued skilled observation and assessment indicated. |
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Select only the elements actually assessed and clinically applicable; do not document examination components that were not performed. Elements such as posterior-field auscultation, chest-expansion assessment, sputum characterization, and pre/post bronchodilator measures are charted when assessed and relevant to the diagnosis, orders, symptoms, or risk.
Short form
Skilled resp assessment: lungs CTA bilat all fields; RR ___ unlabored; SpO2 ___% on RA [or ___ L O2 at target]; no WOB; speaks full sentences; denies cough/sputum/dyspnea; stable. RN judgment applied to detect early decompensation and evaluate the respiratory regimen given [dx]. Continued skilled monitoring indicated. |
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