Document the BP-specific skilled surveillance and management on the days it applies:
Blood pressure against the ordered parameters (including any hold parameters), heart rate, and any orthostatic change (lying/standing).
Symptoms of uncontrolled hypertension (headache, visual change, chest pain, dyspnea, neurologic change) or of over-treatment (lightheadedness, falls).
Antihypertensive administration and tolerance, and the relevant renal function/electrolytes from labs.
MDS-supportive data
Antihypertensive medication days are coded in MDS Section N and the hypertension diagnosis in Section I; related cardiac and renal effects flow to their sections. The record must document the BP values, parameters, and medication response so the coding is supported.
