Assess the ear, hearing, and balance in the context of the skilled reason, and document the judgment:
Hearing status and any change (functional hearing, hearing-aid use and function), and the effect of any deficit on communication and participation in the skilled plan.
For a post-operative ear: the operative site/dressing, drainage, pain, and the surgeon’s precautions (water precautions, no nose-blowing, activity limits); for vertigo: the pattern, triggers, associated symptoms, and the fall risk.
Signs of a complication or acute process (severe pain, fever, purulent drainage, facial-nerve weakness, sudden hearing loss, worsening vertigo).
MDS-supportive data
Hearing is coded in MDS Section B0200 and hearing-aid use in B0300; the ear diagnosis or recent otologic surgery in Section I. The record must document the hearing status, the post-operative or vestibular care, and any change so the MDS is supported.
