POC link. Cite the specific POC order or numbered goal addressed today. “Per POC” is not sufficient — auditors look for a named order or goal.
Med reconciliation. One of the most-cited deficiencies. Document the list compared against current bottles, discrepancies identified or none, the OTC/supplement/herbal screen, and the action taken. “Medications reviewed” alone fails.
Quantified outcomes. Numeric pre/post values are the primary defense. “Improved breathing” does not survive; “RR 26→18, SpO₂ 88→94%” does.
Closed-loop coordination. Log the date/time, person, method, content (SBAR or specific request), and response. If pending, set a follow-up time. Open-ended “notified MD” is not closed-loop.
