.GEN_NORMAL

Skilled general assessment: {well/ill}-appearing, {no/mild} distress, groomed, alert/interactive; nutrition/hydration adequate; denies fever/chills/weight change/appetite loss/night sweats; function at baseline; stable, no constitutional cluster. RN judgment applied to interpret the gestalt and screen for systemic change given {dx}. Continued skilled monitoring indicated.

.GEN_SURVEY

Appearance {well/ill}; distress {none/mild/mod/severe}; grooming/self-care {intact/declined}; interaction {alert/lethargic}; apparent nutrition {adequate/poor}; hydration {adequate/dry}.

.GEN_CONSTITUTIONAL

Fever/chills {y/n}; fatigue/malaise {y/n, impact}; unintentional weight {change/timeframe}; appetite {change}; night sweats {y/n}; cluster {none/possible sepsis/...}.

.GEN_SKILL

General survey interpreted vs baseline; recognized cluster {...}; coordinated evaluation {labs/MD}; reconciled constitutional finding with {med/dx}; directed focused assessment of {system}.

.GEN_TEACH

Reviewed constitutional warning signs (fever, weight loss, fatigue) and the call plan with {pt/cg}; method {teach-back}; mastery {##}%.

.GEN_COORD

Provider notified at {time} re {constitutional finding/cluster}; reported {content}; order received {evaluation}; reassessment {when}.

.GEN_SAFETY

Call for fever, unintentional weight loss, or worsening fatigue; 911 for fever with confusion or acute change in mental status.

.GEN_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.