Document the anticoagulation-specific skilled surveillance and management each day:
The anticoagulant, indication, and dose; for warfarin, the INR against the target range and the protocol-based dose adjustment; for a DOAC, renal function and adherence; for heparin, the relevant monitoring.
Bleeding surveillance: bruising, bleeding gums/epistaxis, hematuria, melena/hematochezia, a drop in hemoglobin, and (after any fall or head strike) delayed-bleed signs.
Interacting medications/diet (for warfarin, vitamin-K intake and new medications) and fall risk (route to Falls).
MDS-supportive data
Anticoagulant days are coded in MDS Section N and the indication (AF, VTE, mechanical valve, stroke) in Section I; bleeding events and falls flow to their sections. The record must document the anticoagulant, the INR/monitoring, and the bleeding surveillance so the coding is supported.
