The skilled service delivered

Names the covered service or the assessment/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 / practical-matter clause

Why the need existed today and can be met only in a SNF (the Chapter 8 coverage hinge)

A quantified outcome or finding

Numeric change against the ordered parameter or the specific prior value

Care-plan / order linkage

Ties the day to a named goal or order (F656/F657)

MDS-supportive data

Carries the data the coder needs for the item the finding drives

Change-of-condition loop (if any)

Notify → response → orders → follow-through (F580)

A valid signature

Contemporaneous, credentialed, with a late-entry note if applicable