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Section Navigation Part 23 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 Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — not duplicate — disease-overlay smart phrases.
.SLP_NORMAL
Skilled sleep assessment: ~{#} hrs, acceptable latency, {few} awakenings, restorative; no excessive daytime sleepiness; contributing-factor review unremarkable; SDB screen negative; [sleep aid safe/effective]; supports function/mood/safety. RN judgment applied to analyze contributors and evaluate aid safety given {dx}. Continued skilled monitoring indicated.
.SLP_HISTORY
Total sleep {#} hrs; latency {#} min; awakenings {#} due to {pain/nocturia/dyspnea/anxiety}; early waking {y/n}; daytime sleepiness {y/n}; naps {#}.
.SLP_SDB
Snoring {y/n}; witnessed apneas {y/n}; gasping {y/n}; morning headache {y/n}; daytime sleepiness {y/n}; STOP-Bang {score}; screen {neg/pos}.
.SLP_AID
Sleep aid {drug/dose/timing}; effect {effective/ineffective}; next-day grogginess/unsteadiness {y/n}; fall risk {y/n}; flagged {y/n}.
.SLP_SKILL
Analyzed contributors {...}; coordinated {pain/dyspnea/nocturia/mood}; reviewed sleep-aid safety; screened SDB; CPAP adherence {data}; reinforced sleep hygiene.
.SLP_TEACH
Reviewed sleep hygiene, sleep-aid safety, {CPAP use} with {pt/cg}; method {teach-back/return-demo}; mastery {##}%.
.SLP_COORD
Provider notified at {time} re {sleep-aid risk/SDB/nocturnal symptoms}; reported {content}; order received {referral/deprescribe/volume plan}; reassessment {when}.
.SLP_NECESSITY
Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.
Section Navigation Part 23 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