“Normal/at-baseline” means the oral cavity is moist and intact, dentition or dentures are functional, and there is no infection or airway concern. Each line states the finding, the comparison to baseline, and the skilled reason a nurse was required — a bare “mouth okay” does not qualify.
Lips and oral mucosa moist and intact without lesions, ulcers, white plaques, or bleeding.
Tongue normal in color and surface without lesions.
Gingiva without bleeding or significant recession; dentition intact or dentures functional without dental pain.
Dentures fitting without ulceration or sore spots.
Pharynx without erythema, exudate, swelling, or asymmetry; no airway concern.
No candidiasis; oral hygiene adequate with the patient or caregiver managing mouth care.
Mucosa moist without problematic dry mouth, and the plan appropriate to continue.
