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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.
.EYE_VISION
Functional vision [near/distance result] with [correction]; new change [none/described — onset/pattern]; [unchanged] from baseline.
.EYE_EXTERNAL
External eye: lids/conjunctiva/sclera [clear/findings]; discharge [none/described]; pupils grossly [equal/reactive]; [unchanged].
.EYE_ACUTE
Acute change: [sudden painless loss / painful red eye with halos / flashes-floaters-curtain / diplopia with neuro signs]; assessment [described]; [emergency escalation].
.EYE_DROPS
Observed [drop/ointment] technique: hygiene, lower-lid pocket, tip not touched, spacing; technique [correct/corrected]; adherence [described].
.EYE_RETINOPATHY
Retinopathy surveillance: last dilated exam [date]; status [current/overdue]; reinforced schedule (see Diabetes/Hypertension overlays).
.EYE_TEACH
Taught [drop technique/warning signs/adherence/low-vision safety]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].
.EYE_NOTIFY
Provider/eye-care 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