Assess the female GYN status in the context of the skilled reason and document the judgment:
For post-gynecologic surgery: any vaginal bleeding (amount/character versus expected), the abdominal or perineal incision, and post-operative complication signs (infection, bleeding, ileus, VTE).
After a hysterectomy: surveillance for vaginal-cuff dehiscence (sudden increased bleeding, a gush of fluid, or — rarely — evisceration), especially with straining.
For a pessary: the fit, retention, and perineal/vaginal skin; for the dependent resident, perineal skin integrity.
MDS-supportive data
Perineal skin/wound is coded in MDS Section M, continence in Section H, and the gynecologic diagnosis or recent surgery in Section I. The record must document the post-operative assessment, the bleeding surveillance, and any skin/wound so the MDS is supported.
