This module maps to the four Medicare skilled-nursing categories. Document the one(s) that apply this visit in coverage language.
Observation and assessment
Assessing epistaxis and judging when a bleed requires escalation, recognizing early pressure injury under a cannula, and evaluating sinus and smell changes require the knowledge and judgment of a licensed nurse. Bleeding assessment and cannula-skin surveillance are the core of observation and assessment for this domain.
Teaching and training
Teaching epistaxis control, cannula skin care, humidification, and sinus self-care — to patient and caregiver competence with return demonstration — is skilled teaching and training.
Management and evaluation of the plan of care
Evaluating whether bleeding, sinus symptoms, and cannula-skin status are stable and coordinating escalation, wound care, or oxygen-interface changes when they are not is skilled management and evaluation of the plan of care.
Skilled procedures
Skilled procedures in this domain include epistaxis control with pressure and packing per order and cannula-skin protective care; nares wound care is documented in Wounds.
