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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.
.GEN_SURVEIL
Whole-person surveillance: afebrile/{T ##}, energy {baseline}, intake {##}%, weight {trend}, participation {status}. Multi-problem plan reviewed; unskilled care achieving purpose. Skilled systemic observation + M&E required daily. Supports Section K/I; goals {###}.
.GEN_SEPSIS
Sepsis surveillance: T {##}, HR {##}, RR {##}, {new confusion}, source {wound/urinary/resp}. Sepsis pathway initiated; SBAR {time} with the constitutional picture; {labs/cultures/evaluation}; representative notified; close monitoring. Reassess {frequency}. Supports Section I.
.GEN_DECLINE
Generalized decline: intake/energy/participation {trend}, weight {loss}, no single cause. Multi-problem plan re-evaluated; provider/dietitian notified; reversible-cause workup ordered; goals-of-care revisited; care plan revised. Reassess {when}. Supports Section K.
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