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DiraChart Clinical Reference
Section NavigationPart 10 of 15PreviousNext 9. Weak vs. strong documentation
Weak — does not survive | Why it fails | Strong — defensible |
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“Ate well. Weight stable.” | No percent, no value, no comparison, no threshold check. | The stable model note in §3: weight vs prior, % intake, diet/texture, aspiration precautions, and the K0300 threshold check. |
“Poor intake.” | No percent, no cause, no action. | “Intake 40% (down from 75%), new coughing at meals — dietitian/provider notified, swallow eval and fortified diet ordered, precautions reinforced.” |
“Tube feeding running.” | No rate, residual, tolerance, or site — Section K and skilled care unproven. | “Enteral feed at [rate], residual within policy, tolerated, PEG site clean, free-water flushes given.” |
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