Daily-note bank — change-of-condition / at-risk days
Scenario
Model daily note (edit to the shift)
Program decline
Ambulation fell 75→25 ft with increased assist and new knee pain 6/10 over three sessions — program held, provider/therapy notified, PT re-eval and analgesic requested, Section GG/CAA updated, care plan revised.
Goal met / step-down
Now ambulates 150 ft independently, meeting the discharge goal — walking program discontinued, maintenance plan substituted, Section GG updated to improved performance, care plan revised.
Tolerance event
During transfer training, new dizziness and BP drop on standing — activity stopped, orthostatics obtained, provider notified, program held pending review; event and vitals documented.
Linked disease-specific scenarios
Skilled physical/occupational therapy episodes route to the relevant clinical reference (they are not restorative); fall events during ambulation route to the Falls reference; ADL/Section GG capture routes to the Functional reference.
