No mood screen, no engagement/participation link, no caregiver picture — misses a psychosocial factor affecting the skilled course.
The psychosocial-support model note in §3: mood/PHQ trend, participation in the skilled plan, the caregiver/discharge picture, and the reason management-and-evaluation was required.
“Refused therapy.”
A bare refusal with no assessment, cause, impact, or action.
The decompensation model note in §4: the mood/engagement change, its impact on the skilled goals, the support/re-engagement plan, notification, and the plan revision.
“Family educated.”
No caregiver, no task, no competence measure.
“Discharge caregiver (daughter) taught transfers and the medication schedule; return-demo 8/8; warning-sign teach-back 100%.”
