Document the whole-person status and the integrating judgment:
Constitutional signs: temperature and infection screen, energy/activity tolerance, appetite and intake, weight trend, and overall functional participation.
Early sepsis surveillance where at risk (fever/hypothermia, tachycardia, tachypnea, new confusion, hypotension) and the suspected source.
For a complex resident, the interacting problems and whether the unskilled care is achieving its purpose (the management-and-evaluation view).
MDS-supportive data
Fever and constitutional findings support the observation basis; weight/intake are coded in MDS Section K, infection in Section I, and other symptoms in Section J. The record must document the systemic assessment and the multi-problem management so the coding is supported.
