General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.31
Mouth & Oral
Skilled documentation when the mouth is the reason for or a factor in a Part A stay — post-oral/maxillofacial surgery care, chemotherapy- or radiation-induced mucositis, oral care for the dependent/NPO resident to prevent aspiration pneumonia, and oral infection or bleeding. Oral status directly affects nutrition, infection risk, and comfort in the skilled resident.
Module code | SNF-MOUTH |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Nutrition (intake/dysphagia) · Respiratory (aspiration) · Skin (mucosa) · Skilled-Daily · Change of Condition |
MDS section(s) | L (oral/dental status) · K (nutrition; oral intake) · I (oral diagnoses; recent surgery; mucositis) |
Skilled category (Ch. 8) | Covered skilled procedures (post-operative oral care; complex oral/mucositis care) · observation & assessment of an oral change affecting nutrition/infection · teaching |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Oral/dental and nutrition references: F675/F692 — 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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