Document the psychosocial factors affecting the skilled course and the caregiver picture:
Mood and affect (a PHQ-based screen where used), engagement and motivation, and the effect on participation in the skilled plan (therapy, ADL, self-care learning).
Refusal or disengagement, its pattern and trigger, and its impact on the skilled goals; coping, support system, and any grief/adjustment reaction.
Caregiver capacity for a safe discharge: who the caregiver is, what care they must provide, and their current competence and confidence (the teaching target).
MDS-supportive data
Mood is coded in MDS Section D (PHQ), preferences in Section F, and participation/goals/discharge planning in Section Q; the diagnosis in Section I. The record must document the mood screen, the psychosocial effect on the plan, and the discharge/caregiver picture so the MDS is supported.
