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Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.
.COMM_STATUS
Communication: makes self understood {level}, understands others {level}, deficit {type}. Method {board/writing/AAC/gestures} — effective for {participation/reporting}. Able to signal pain/needs {y/n}. Skilled management to enable the plan required. Supports Section B; comm goal {###}.
.COMM_CHANGE
New/worsening {aphasia/speech change} (vs baseline). BE-FAST {result}. Stroke/transfer pathway activated; provider + representative notified; last-known-well {time}. Reassess on return. Time-critical. Supports Section B/I. (Neuro reference.)
.COMM_METHOD
Communication method {established/rebuilt}: {method}; reliable call-signal {established}; reassessed for unreported pain/change {finding}; SLP/provider engaged. Skilled safe-communication establishment required. Supports Section B.
Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next 