“Incision healing. Ambulated with PT.”

No incision detail, no neurovascular status, no precautions, no assist/distance — the skilled post-surgical assessment is unproven.

The post-TKR model note in §3: incision findings, neurovascular status, weight-bearing/precautions, pain with movement, therapy participation, and VTE prophylaxis.

“Leg swollen.”

No comparison, no measurement, no action — misses a possible DVT.

The VTE model note in §4: unilateral calf swelling/warmth/tenderness, provider notification, Doppler ordered, prophylaxis reviewed, embolic monitoring.

“Precautions maintained.”

Which precautions? Observed how?

“Posterior hip precautions maintained: no flexion beyond 90°, no adduction/internal rotation; abduction wedge in use during rest.”