Medicare-Compliant SBAR Clinical Documentation System — Skilled Nursing Visits
Designed and implemented a structured SBAR (Situation, Background, Assessment, Recommendation) documentation system for Medicare-compliant skilled nursing home visit notes covering Week 1–9 visit cycles. System was built to withstand ADR (Additional Documentation Request) audits by ensuring clinical necessity justification, goal-tracking, and homebound status documentation are embedded at every visit. Applied clinical reasoning and AI-assisted workflows to produce audit-ready notes for a US-based home health agency.