Assess the mouth in the context of the skilled reason and document the judgment:
The oral mucosa, gums, tongue, and dentition (lesions, ulcers, erythema, white plaques suggesting thrush, bleeding), and the effect on chewing, swallowing, and intake.
For a post-oral-surgical course: the surgical site, any wiring/appliance, swelling, drainage, and bleeding; for mucositis: the grade/extent, pain, and intake impact.
Signs of an oral infection or systemic spread and, for the dependent/NPO/tube-fed resident, the adequacy of oral care and aspiration risk.
MDS-supportive data
Oral/dental status is coded in MDS Section L, nutrition/intake in Section K; the oral diagnosis, recent surgery, or mucositis in Section I. The record must document the oral assessment, the specialized oral care, and the intake/infection impact so the MDS is supported.
