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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.
.NECK_EXAM
Neck [no mass/mass], asymmetry [none/described]; ROM [full/limited]; incision [healing/complication]; [unchanged] from baseline.
.NECK_THYROID
Thyroid [non-enlarged/enlarged/nodule], tenderness [none/described]; systemic symptoms [none/described — managed in Endocrine]; medication [agent].
.NECK_AIRWAY
Trachea [midline/deviated]; stridor [none/present]; airway [patent/compromised]; assessment [described]; [action].
.NECK_POSTOP
Post-thyroidectomy: incision [intact]; hypocalcemia signs [perioral numbness/tetany/Chvostek/Trousseau — none/present]; hematoma/airway [none/concern]; [action].
.NECK_MASS
Mass [location/size], mobility [mobile/fixed], consistency [soft/hard], tenderness [yes/no]; assessment [benign/concerning]; [action].
.NECK_TEACH
Taught [thyroid symptoms/post-op warning signs/incision care/changes to report]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].
.NECK_NOTIFY
Provider 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 