Every clinical action documented should include the reasoning that required RN judgment. Compare:
Unskilled wording
Took vital signs. BP 152/88. Reviewed medications with patient.
Skilled wording
BP 152/88 — outside the provider parameter (>150/90). Assessed for symptoms (headache, vision changes, chest pain — all denied). Reviewed antihypertensive adherence — patient reports missing morning amlodipine ×2 days due to running out. Coordinated a 30-day refill with pharmacy; reinforced consistent dosing for stroke/MI risk reduction. Will recheck BP next visit. RN judgment applied to evaluate the parameter exceedance, identify the adherence gap, and prevent an end-organ event.
When in doubt, ask: could a family member with a 30-minute tutorial do this? If yes, the visit is in trouble. If no — because of disease complexity, parameter judgment, or risk surveillance — name that reason in the note.
