← Document menu Nursing Home · DiraChart 6.1 “WNL” alone DiraChart Clinical Reference
Section Navigation Part 11 of 20 1. General Section 2. 6.1 “WNL” alone 3. What changed 4. 6.2 Vague daily-skilled need (the homebound-replacement failure) 5. What changed 6. 6.3 Teaching without mastery 7. What changed 8. Extended recurring patterns (SNF) 9. The daily-skilled gap 10. Cloned / carried-forward note 11. Reference to “baseline” with no value 12. Unquantified outcome 13. MDS not supported by the record 14. Care plan not individualized or not updated 15. Restorative program not documented 16. Open-loop coordination or missed notification 17. Maintenance coverage misframed 18. Restraint / psychotropic documentation gap 19. Notice not issued or not documented 20. Sources and clinical references Previous Next Reference to “baseline” with no value Fails: “stable from baseline” / “unchanged” — a covering nurse and a reviewer cannot know the baseline. Survives: the actual value with its objective reference — “BP 124/76 (vs 128/74 yesterday); weight 178 lb (vs 178, ±0),” or “glucose 118, within the ordered 80–180.” Section Navigation Part 11 of 20 1. General Section 2. 6.1 “WNL” alone 3. What changed 4. 6.2 Vague daily-skilled need (the homebound-replacement failure) 5. What changed 6. 6.3 Teaching without mastery 7. What changed 8. Extended recurring patterns (SNF) 9. The daily-skilled gap 10. Cloned / carried-forward note 11. Reference to “baseline” with no value 12. Unquantified outcome 13. MDS not supported by the record 14. Care plan not individualized or not updated 15. Restorative program not documented 16. Open-loop coordination or missed notification 17. Maintenance coverage misframed 18. Restraint / psychotropic documentation gap 19. Notice not issued or not documented 20. Sources and clinical references Previous Next 