General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.33
Taste & Swallowing
Skilled documentation of swallowing for the Part A day — dysphagia after stroke, head-and-neck surgery, or neuromuscular disease; aspiration-precaution management; swallow-evaluation coordination and diet-texture progression; and taste changes affecting intake. Dysphagia is a leading, preventable cause of aspiration pneumonia and a core skilled focus. Nutrition detail routes to the Nutrition reference.
Module code | SNF-SWALLOW |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Nutrition · Neurological · Respiratory (aspiration) · Mouth/Oral · Skilled-Daily · CVA overlay |
MDS section(s) | K0100 (swallowing disorder / signs) · K0510 (nutritional approaches) · C · I (dysphagia; stroke) |
Skilled category (Ch. 8) | Observation & assessment of swallowing/aspiration risk · management & evaluation (aspiration-precaution and diet plan) · teaching (swallow strategies) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Nutrition/quality references: F692/F684 — secondary to the coverage analysis. |
How to use this module Fill every model note and smart phrase with the shift’s actual values and the resident’s current orders — these are structured examples to edit, never phrases to copy. The universal writing rules in Foundations (the necessity sentence, quantified outcomes, teach-back, closed-loop coordination, MDS-supportive documentation, and care-plan linkage) apply throughout and are not reprinted here. Disease-specific days route to the overlays. Verify each threshold and citation against the current source before use. |
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