Foundations

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Trace DC6-8

DiraChart Clinical Reference
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1.1 Why “WNL” alone fails

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Why three parts

  • Skilled action — answers what was done that required RN-level judgment.
  • RN-level reason — answers why a nurse rather than a layperson or aide.
  • Measurable effect — answers what changed. Numeric. Quantified. Not subjective.

Skip any one and the sentence becomes a fragment an auditor can pick apart. All three together close the loop.

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