No mucosa detail, no intake/infection link, no skilled rationale.
The mucositis or dependent-care model note in §3: the mucosa findings, the specialized care, the intake/infection impact, and the reason skilled oral care was required.
“Sores in mouth.”
No grade, no pain/intake impact, no action.
“Grade 2 mucositis (patchy erythema, small ulcers), pain controlled to allow intake with the ordered rinse/topical analgesic and modified diet; no infection signs.”
“Poor intake.”
Misses the oral cause; no oral assessment.
Document the oral finding limiting intake (mucositis/lesion/infection), the management, and the nutrition coordination.
