9. Weak vs. strong documentation
Weak — does not survive | Why it fails | Strong — defensible |
|---|---|---|
“Resident agitated. PRN given.” | No triggers, no non-pharm attempt, no target symptom, no effect — reads as chemical management. | The escalation model note in §4: behavior data, non-pharm first, indication/target symptom, notification, GDR status, monitoring, and Section E linkage. |
“Antipsychotic continued.” | No indication, target symptom, monitoring, or GDR consideration — an unnecessary-drug exposure. | “Antipsychotic at the reduced dose for [indication]; target symptom [x] stable; no EPS/sedation; next GDR review [date].” |
“Behaviors this shift.” | No frequency/intensity/trigger — Section E unsupported. | “2 episodes of afternoon agitation, triggered by [x], resolved with redirection and a walk; no PRN needed.” |