Assess the neck/thyroid in the context of the skilled reason and document the judgment:
For a post-thyroidectomy/neck-surgery course: the incision and neck for swelling or an expanding hematoma, the airway and voice (hoarseness, stridor), and calcium status (numbness/tingling of the lips/fingers, muscle twitching — hypocalcemia).
For a thyroid disorder: the relevant symptoms (hypo- vs hyperthyroid), heart rate/rhythm and temperature, and the medication response.
For a cervical issue: immobilization per order, neuro-vascular status of the extremities, and pain.
MDS-supportive data
Thyroid/neck diagnoses or recent surgery are coded in MDS Section I, thyroid medications in Section N, oxygen in Section O0110. The record must document the neck/thyroid assessment, the post-operative surveillance, and any change so the MDS is supported.
