Skilled verbs cheat sheet — Field card from Home Health 101

Why this exists

Visits get denied not because the work wasn't skilled, but because the chart didn't read that way. Skilled need shows up in the verbs you choose. Below are the twenty verbs auditors look for, grouped by what they do, each with a sample phrase from a real chart. Pull this up next time the right words won't come.

Assessment — clinical judgment in action

Assessed: "Assessed dyspnea on exertion; SpO₂ dropped 96 → 89% after 20 ft ambulation; instructed pursed-lip breathing."
Evaluated: "Evaluated gait with rolling walker; observed bilateral knee instability and pelvic drop during stance phase."
Identified: "Identified duplicate metoprolol prescription during med reconciliation — one from PCP, one from cardiologist."
Monitored: "Monitored INR trend; holding stable at 2.3 on current warfarin dose; will recheck in 2 weeks."
Measured: "Measured wound: 2.1 × 1.4 × 0.3 cm, decreased from 2.6 × 1.7 × 0.5 last visit; granulation tissue present."

Intervention — skilled care delivered

Instructed: "Instructed daughter (primary caregiver) in two-person transfer with gait belt; daughter performed safely on 2nd attempt."
Taught: "Taught patient signs of hypoglycemia and when to use glucose tabs; patient verbalized correct response."
Re-instructed: "Re-instructed patient in insulin draw-up using step card after 4/10 accuracy last visit; will reassess next visit."
Trained: "Trained spouse in tracheostomy suctioning; spouse demonstrated full technique independently after two repetitions."
Demonstrated: "Demonstrated safe sit-to-stand transfer from low recliner; patient followed with verbal cuing on third attempt."

Adjustment — the plan changed because of you

Adjusted: "Adjusted home exercise program: removed step-ups due to knee pain, added ankle pumps and quad sets."
Modified: "Modified transfer technique for narrow bathroom doorway; taught spouse pivot from chair to commode."
Progressed: "Progressed gait training from rolling walker to single-point cane indoors, contact-guard assist for stairs."
Advanced: "Advanced wound care from wet-to-dry to hydrocolloid dressing per new MD order; demonstrated to caregiver."
Discontinued: "Discontinued compression wrap due to skin tear concerns; notified MD; awaiting new order."

Coordination — communication that affected care

Notified: "Notified Dr. Lin of BP 168/96; new order received to add lisinopril 10 mg daily; patient and spouse instructed on new med."
Reported: "Reported new productive cough and low-grade fever (100.4 °F) to on-call MD; advised to monitor and call back if worsens."
Coordinated: "Coordinated home health aide schedule to align AM care with PT visit; spouse confirmed by phone."
Reconciled: "Reconciled discharge medication list against home meds; identified two duplicates and one omission; notified PCP."
Escalated: "Escalated caregiver concern (verbal aggression toward patient) to clinical manager; APS report initiated per agency policy."

Words to retire

"Tolerated well." Says nothing about what you did or what changed.
"Stable, no changes." The fastest path to a denial.
"Patient educated on…" without naming what they demonstrated or struggled with.
"Continue plan of care." Reads as autopilot. Say why skill is still needed.
"Patient is homebound." Don't assert it; paint the picture.
"Wound is healing." Measure it. The verbs above do the work.

One rule

These verbs aren't paperwork hygiene. They're how you make the skilled work you're already doing visible — to the auditor, to the next clinician, to the record. Document the skill, not the conclusion.

Companion to Home Health Charting Basics and the Do / Don't card.