Nutrition Weight Dysphagia

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Trace DC48-10

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1. Purpose and clinical relevance

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9. Weak vs. strong documentation

Weak — does not survive

Why it fails

Strong — defensible

“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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