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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.
.GU_ASSESS
Skilled GU/renal assessment: voiding [pattern/volume]; urine [color/clarity/odor/hematuria]; [no] dysuria/urgency/retention; mental status [vs cognitive baseline].
.GU_CATHETER
[Catheter type] patent, output [amount/color], secured [site], bag below bladder; insertion/stoma site [condition]; no obstruction; closed system intact.
.GU_INFECT
Infection surveillance: [dysuria/frequency/suprapubic-flank pain], [temp], [mental-status change]; assessment [no infection / probable UTI / urosepsis concern]; [action].
.GU_FLUID
Fluid balance: weight [value vs target], edema [grade/location], intake/output [where ordered], [dyspnea]; assessment [at baseline / overload concern]; [action].
.GU_RETENTION
Retention assessment: suprapubic [distension/tenderness], sensation [complete/incomplete]; post-void residual [mL by scan]; [drained volume / action].
.GU_TEACH
Taught [catheter care/CISC/fluid targets/UTI signs]; [patient/caregiver] return-demonstrated [result]; remaining gaps [none/described].
.GU_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 