Assess the eye and vision in the context of the skilled reason, and document the judgment:
Vision status and any change from baseline (acuity to the resident’s functional level, visual fields where relevant, new deficit); the affected versus unaffected eye.
For a post-operative eye: the eye-drop/ointment regimen (agents, schedule, technique), the required positioning and shield, and the operative-eye findings (redness, discharge, pain, swelling).
Signs of a complication (increasing pain, worsening redness, discharge, sudden vision change) and, for the dependent resident, corneal protection (blink, closure, lubrication).
MDS-supportive data
Vision is coded in MDS Section B1000 (and B0100 if comatose); the eye diagnosis or recent ophthalmic surgery in Section I. The record must document the vision status, the post-operative eye care, and any change so the MDS is supported.
