Document the post-surgical skilled surveillance and care each day:
The incision/surgical site (approximation, drainage, erythema, warmth), any drain (output/character, patency), and the operative-limb or -site status (neurovascular where relevant).
VTE-prophylaxis administration and calf/limb assessment; pain with movement and its effect on therapy participation; and bowel/respiratory function (ileus, atelectasis).
Surgical precautions and weight-bearing/activity status per the surgeon’s order, and function (Section GG usual performance).
MDS-supportive data
Function is coded in MDS Section GG, therapy/IV medication in Section O, pain in Section J, VTE prophylaxis in Section N, and the procedure in Section I. The record must document the surgical course, function, prophylaxis, and complication surveillance so the MDS is supported.
