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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.
.EGEN_CONSENT
Perineal/genital skin assessment performed with consent, privacy, and chaperone per policy.
.EGEN_SKIN
Perineal/genital skin [intact/erythema/denudation/breakdown]; moisture [controlled/uncontrolled]; [unchanged/changed] from baseline.
.EGEN_DIFF
Determination: [incontinence-associated dermatitis — diffuse, moisture pattern, folds] vs [pressure injury — localized over bony prominence, staged]; treatment [barrier/offloading]; [action] (see Wounds).
.EGEN_WOUND
Perineal/genital wound [location/size/depth/tissue/exudate]; stage [per Wounds]; trajectory [described]; [action].
.EGEN_NECRO
Necrotizing-infection screen: pain out of proportion [yes/no], discoloration/necrosis [none/described], crepitus [yes/no], systemic toxicity [none/described]; assessment [none/Fournier concern]; [action].
.EGEN_TEACH
Taught [perineal care/barrier application/moisture management/warning signs/device-site care]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].
.EGEN_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