← Document menuHome Care · DiraChart1.1 Why “WNL” alone fails
DiraChart Clinical Reference
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- 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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