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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.
.MREPRO_CBI
Post-{TURP/prostatectomy} CBI day {#}: outflow {color/clearing/clots}, catheter {patent/traction}, output {adequate/correlated}, distension {none}, pain {##}. Covered skilled irrigation + hemorrhage surveillance. Supports Section H; goal {###}. (Continence reference.)
.MREPRO_HEMORRHAGE
Post-op hemorrhage/clot retention: outflow {bright red/clots}, {slowing/stopped}, distension {y}, pain {##}. Hand-irrigated per protocol; rate increased per order; vitals/outflow monitored; anticoagulation reviewed; SBAR; orders; representative notified. Reassess {when}. Supports Section H.
.MREPRO_POSTOP
Post-{scrotal/testicular} surgery day {#}: site {clean/dry}, swelling {expected/supported}, hematoma {none}, pain {##}, scrotal support {in place}. Skilled post-operative site care. Supports Section I; goal {###}.
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 