4. Abnormal findings — the necessity chain
Finding → severity → comparison → risk → intervention → notification (provider + representative) → orders → response → reassessment.
Model abnormal 1 |
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Surgical-site infection: the incision with increasing erythema extending beyond the margins, warmth, purulent drainage, and a low-grade fever — concerning for a surgical-site infection. The provider notified with the wound findings, a wound culture and possible antibiotics ordered, the dressing regimen changed per order, the limb/site and systemic signs reassessed, and the care plan revised; the responsible party notified. Will reassess; supports the Section I/N update. Skilled recognition and management required — a daily SNF-level need. (Wound detail routes to the Skin reference.) |
Model abnormal 2 |
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Post-operative VTE or bleeding: new unilateral calf swelling, warmth, and tenderness (concerning for a DVT), or excessive incision/drain bleeding or a falling hemoglobin (concerning for post-operative bleeding). The finding assessed and measured, the provider notified, a Doppler or labs ordered per order, prophylaxis/anticoagulation reviewed per parameters, the resident monitored for embolic or hemodynamic signs, and the responsible party notified. Will reassess; supports the Section update. Skilled recognition required, as post-operative VTE and bleeding are time-critical. (Anticoagulation routes to its overlay; DVT to Peripheral Vascular.) |