Daily-note bank — change-of-condition / at-risk days
Scenario
Model daily note (edit to the shift)
New facility-acquired injury
New Stage 2 sacral injury on the weekly sweep, 2.2 × 1.5 × 0.1 cm, not present on admission — POA documented; provider notified, treatment ordered; repositioning/surface intensified; dietitian consulted; Section M coded; care plan revised; avoidability determined.
Wound infection
Stage 3 wound with increased purulence, periwound erythema +3 cm, odor, low-grade fever — provider notified, culture and possible antibiotics ordered, dressing changed; measurements/photos updated; Section M/N updated; reassess for systemic signs.
Suspected deep-tissue injury
New non-blanchable maroon area over the heel, boggy and warm — suspected deep-tissue injury; offloaded, provider notified, staged and measured, POA documented, Section M coded, prevention intensified.
Linked disease-specific scenarios
Diabetic-foot ulcers and neuropathy route to the Diabetes overlay; arterial/venous etiology and perfusion route to Peripheral Vascular; nutrition support for healing routes to the Nutrition reference.
