Document the stroke-specific skilled rehabilitation and surveillance each day:
The deficit set and its trajectory (motor strength, sensation, swallowing, communication, cognition, vision), the therapy carryover, and function (Section GG usual performance).
Secondary-prevention parameters: blood pressure against the ordered goal, the antithrombotic regimen (antiplatelet or anticoagulation) and bleeding surveillance, and glucose where relevant.
Complication surveillance: aspiration signs (route to Taste/Swallowing), DVT signs, post-stroke mood, and — critically — any new or worsening deficit signaling a recurrent stroke.
MDS-supportive data
Function is coded in MDS Section GG, cognition in Section C, speech/vision in Section B, therapy in Section O, antithrombotic medications in Section N, and stroke in Section I. The record must document the deficit trajectory, the rehabilitation nursing, secondary prevention, and complication surveillance so the MDS is supported.
