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- Date, time-in, and time-out documented.
- Persons present (resident, family/representative, others) identified; interpreter use noted if applicable.
- Daily skilled need reaffirmed with a resident-specific reason (the SNF replacement for homebound) — what skilled service was required today.
- Practical-matter / SNF-level statement present — why the need can be met only in this SNF on an inpatient basis.
- Benefit-period status tracked (day of the stay; days used/remaining) so the note aligns with the covered period.
- Vital signs documented with technique context (rest time, cuff size, position); pain assessed (PQRST, or PAINAD for non-communicative residents).
- Medication administration/reconciliation completed against current orders; OTC/supplement screen noted.
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