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Section Navigation Part 22 of 25 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. Subjective — ask 10. Objective — observe 11. Measure 12. 8. Interventions performed 13. 9. Patient and caregiver teaching 14. 10. Response and reassessment 15. 11. Physician or provider notification 16. 12. Red flags and emergency escalation 17. 13. Skilled-need justification 18. 14. Medical-necessity statement 19. 15. Homebound relevance 20. 16. Weak vs. strong documentation 21. 17. Common audit and denial risks 22. Smart phrases 23. Normal narrative bank — stable / at-baseline 24. Abnormal narrative bank — focused / at-risk 25. 19. Sources and clinical references Previous Next Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — not duplicate — the parent and overlay phrases. Chart only the elements actually assessed.
.EAR_HEARING
Functional hearing [response to voice, each side] [with aids]; new/sudden change [none/described — onset/ear]; [unchanged] from baseline.
.EAR_EXTERNAL
External ear/canal: [clear/deformity/swelling/drainage/cerumen]; otalgia [none/described]; drainage [none/described]; fever [yes/no].
.EAR_VERTIGO
Vertigo: type [spinning/light-headed], triggers [described], duration [time]; central signs [gait/speech/diplopia/weakness/headache — none/present]; assessment [peripheral/central]; [action].
.EAR_AID
Hearing aids: fit [correct], function [working], battery [managed]; observed [insertion/removal/cleaning] — technique [correct/corrected].
.EAR_TINNITUS
Tinnitus: [new/chronic], associated [hearing change/neuro symptoms]; [stable/changed]; [action].
.EAR_TEACH
Taught [aid care/sudden-loss warning signs/central-vertigo signs/fall prevention]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].
.EAR_NOTIFY
Provider/ENT notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [parameter] next visit.
Section Navigation Part 22 of 25 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. Subjective — ask 10. Objective — observe 11. Measure 12. 8. Interventions performed 13. 9. Patient and caregiver teaching 14. 10. Response and reassessment 15. 11. Physician or provider notification 16. 12. Red flags and emergency escalation 17. 13. Skilled-need justification 18. 14. Medical-necessity statement 19. 15. Homebound relevance 20. 16. Weak vs. strong documentation 21. 17. Common audit and denial risks 22. Smart phrases 23. Normal narrative bank — stable / at-baseline 24. Abnormal narrative bank — focused / at-risk 25. 19. Sources and clinical references Previous Next 