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Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.
.ORAL_MUCOSITIS
Mucositis grade {#}: mucosa {erythema/ulcers/extent}, pain {##} {controlled for intake}, oral care regimen {rinse/topical} per order, diet {modified}, infection signs {none}. Intake {level}. Skilled mucositis assessment/care required. Supports Section L/K; goal {###}. (Nutrition reference.)
.ORAL_DEPENDENT
Skilled oral care (dependent/tube-fed): per aspiration-prevention protocol; mucosa {moist/intact}, no thrush/lesions, mouth clear of secretions. Recognized measure to reduce aspiration pneumonia. Supports Section L. (Respiratory reference.)
.ORAL_POSTOP
Post-oral-surgery day {#}: site {approximation/swelling/drainage/bleeding}, {wiring/appliance}, airway {clear}. Precautions observed. Covered skilled oral care; complication/airway surveillance. Supports Section L/I; goal {###}.
Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next 