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DiraChart Clinical Reference
Section NavigationPart 18 of 29PreviousNext Three markers of a skilled service
- Complexity — the service requires understanding of disease processes, medication effects, or device function a non-professional cannot supply.
- Judgment — the nurse must interpret findings, apply parameters, decide when to escalate, or modify the plan based on response.
- Risk — the patient’s condition or treatment carries risk that requires professional surveillance to detect early.
Documentation that reads as unskilled “Vital signs taken” — without parameters, response, or judgment. “Medications administered” — without technique, monitoring, or teaching. “Patient educated” — without specific topic, method, or mastery measure. “Assessed” without clinical reasoning attached. Custodial care, ADL assistance, companionship, transportation. |
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