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Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.
.EAR_POSTOP
Post-{procedure} day {#}: operative ear {dressing/drainage/pain}, {fever?}, facial symmetry {intact}. Surgeon precautions ({water/no nose-blow/activity}) observed/reinforced. Covered skilled ear care; complication surveillance. Supports Section B; ear goal {###}.
.EAR_VERTIGO
Acute vertigo: onset {pattern}, {nausea/unsteadiness}, fall risk {high}. Fall precautions intensified; central-cause screen ({focal deficit/headache/gait}); provider notified; {vestibular measures/workup}; representative notified. Reassess {when}. (Falls/Neuro references.)
.EAR_HEARING
Hearing management: aid {in place/functioning}, communication strategies {used}; deficit {distinguished from confusion}; participating in {teaching/therapy}. Skilled management to enable the skilled plan. Supports Section B.
Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next 