Assess communication in the context of the skilled reason and document the judgment:
The ability to make self understood and to understand others (Section B), the type of deficit (expressive/receptive aphasia, dysarthria, cognitive-communication), and any change from baseline.
The communication method in use (verbal, writing, communication board, gestures, AAC device) and its effectiveness for participation, teaching, and reporting needs.
The safety implication of the deficit — the resident’s ability to call for help and to report pain or a change — and any contributing factor (hearing, cognition, airway/trach).
MDS-supportive data
The ability to make self understood (B0700) and to understand others (B0800) are coded in MDS Section B, cognition in Section C; the diagnosis in Section I. The record must document the communication status, the method, and any change so the MDS is supported.
