Assess vascular status and document the skilled judgment:
Peripheral pulses and perfusion (color, temperature, capillary refill, hair/skin changes) and any difference between limbs; arterial vs venous features.
Edema (location, grade, symmetry) and the response to compression/elevation; for a possible DVT, unilateral swelling, warmth, tenderness, and calf pain.
Vascular ulcers (arterial vs venous features — route wound measurement/staging to Skin) and the compression-therapy order and tolerance.
MDS-supportive data
Vascular (arterial/venous) ulcers are coded in MDS Section M; anticoagulant days in Section N; edema/pain in Section J; the vascular diagnosis in Section I. The record must document the vascular assessment and any ulcer/compression so the MDS is supported.
