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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.
.HEAD_EXAM
Scalp [intact/lesion]; skull [nontender/tender/step-off]; face [symmetric/asymmetric]; hair/scalp hygiene [described]; [unchanged] from baseline.
.HEAD_STRIKE
Head strike [mechanism/time]; anticoagulant [agent]; serial neuro check: [alert/pupils/headache/vomiting/focal deficit]; [unchanged/evolving]; precautions [taught].
.HEAD_HA
Headache: onset [sudden/gradual], severity [score], quality [described], associated [symptoms]; red-flag features [none/described]; [action].
.HEAD_GCA
Temporal arteries [nontender/tender]; jaw claudication [yes/no]; visual change [yes/no]; assessment [no GCA/GCA concern]; [action].
.HEAD_TEACH
Taught [head-injury precautions/warning signs/lower threshold on anticoagulant/scalp-wound care]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].
.HEAD_NOTIFY
Provider notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [parameter] next visit.
.HEAD_NECESSITY
Skilled [surveillance/assessment] required to [reason]; measurable effect: [finding caught or plan decision].
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 