Assess the head/scalp in the context of the skilled reason and document the judgment:
For a post-neurosurgical/craniotomy course: the incision/staples (approximation, drainage, erythema, swelling), any dressing or drain, and — paired with the neuro exam — signs of a complication (increased intracranial pressure, infection, or a CSF leak).
For a post-fall head strike: the scalp survey (laceration, hematoma), neuro checks per protocol, and the delayed-bleed watch (route the protocol to Falls).
Scalp integrity in the immobile resident (pressure areas at the occiput) and any scalp wound’s characteristics and care.
MDS-supportive data
Recent neurosurgery or head injury is coded in MDS Section I, a scalp wound in Section M, with function/cognition flowing to Sections C and GG. The record must document the head/scalp assessment, the incision/wound care, and any neurologic change so the MDS is supported.
