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Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.
.MSK_POSTOP
Post-{procedure} day {#}: incision {approximation/drainage/erythema}, {staples/sutures} intact, swelling {status} with {elevation/ice}. Operative-limb NV: {color/warmth/pulses/sensation/movement/cap refill}. Weight-bearing {status}; precautions {list} maintained. Pain {##} with movement (vs {prior}); therapy {participation}. VTE prophylaxis {given}. Skilled post-surgical assessment required daily. Supports Section GG/O/N; rehab goal {###}.
.MSK_REHABNURSE
Rehabilitation-nursing carryover: {transfers/ambulation} with {assist} and {precautions} maintained; restorative reinforcement of the therapy program, CNA return-demo {#/#}. Pain controlled for participation; incision intact. RN evaluation of the plan. Supports Section GG and O0500.
.MSK_COMPLICATION
{Wound complication / calf finding}: {description vs prior}. Provider notified; {culture/Doppler/orders}; {dressing/prophylaxis} reviewed; {systemic/embolic} monitoring. Reassess {when}. Skilled recognition of a post-operative complication required.
Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next 