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Section Navigation Part 9 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, denial and survey risks 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 8. MDS & care-plan linkage Psychotropic days are coded in Section N, behaviors in Section E, mood in Section D, cognition in Section C; the record must support each (F641). Each note ties to the behavioral/psychotropic care-plan problem/goal (baseline F655 → comprehensive F656 → revision F657). A significant behavioral change may trigger a Significant Change assessment (F637).
Section Navigation Part 9 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, denial and survey risks 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 