Assess the post-surgical limb and the functional course, and document the skilled judgment:
The surgical site/incision (approximation, drainage, erythema, warmth), and the operative-limb neurovascular status (color, warmth, pulses, capillary refill, sensation, movement).
Weight-bearing status and the surgeon’s precautions (e.g., hip-precaution range limits, spinal-precaution restrictions), and adherence to them.
Pain with movement and its effect on therapy participation; VTE-prophylaxis administration and any calf pain/swelling; and function (Section GG usual performance).
MDS-supportive data
Function is coded in MDS Section GG (self-care and mobility); therapy minutes and IV medication in Section O; pain and falls in Section J; anticoagulant (VTE prophylaxis) in Section N; the orthopedic diagnosis in Section I. The record must document the surgical course, function, and prophylaxis so the MDS — and the PDPM function/therapy picture — is supported.
