Assess neurological status and the functional course, and document the skilled judgment:
Level of consciousness and orientation; a focused deficit exam appropriate to the diagnosis (facial symmetry, speech, strength and drift by extremity, sensation, coordination, gait) and any change from the documented baseline.
Swallowing and aspiration risk after a stroke (route detail to Nutrition), and communication ability (aphasia/dysarthria).
For a seizure disorder: precautions, any seizure activity (type, duration, post-ictal state), and medication administration; for cognition, BIMS-relevant status and any delirium.
MDS-supportive data
Function is coded in MDS Section GG; cognition in Section C (BIMS); vision/hearing/speech in Section B; therapy in Section O; the neurological diagnosis in Section I. The record must document the deficit exam, function, and any change so the MDS is supported.
