2. What the clinician must capture each skilled day

A defensible daily skilled note addresses each of the following, scaled to the resident’s condition and the day’s skilled focus:

• The skilled service delivered — the covered procedure, or the observation & assessment, teaching, or care-plan management that required a licensed clinician.
• The licensed-level reason — why a nurse rather than a layperson or aide (disease complexity, parameter judgment, or risk surveillance).
• The daily basis — why the skilled need existed today, not as a standing conclusion.
• The practical-matter / SNF-level element — why the service can be provided only in this SNF on an inpatient basis.
• A quantified finding or outcome — numeric change against the ordered parameter or the specific prior value.
• Care-plan and order linkage — the named goal or order the day advances.
• MDS-supportive data — the values the coder needs for the item the day drives (Section O, N, GG, M, J, K).
• Coordination / change-of-condition loop — any provider and representative notification with a closed loop.