Any codable item the shift touched (Section GG function, J pain/falls, K weight/nutrition, M skin, N meds, O treatments/restorative) has the supporting data in the record.
The note and the MDS agree — nothing is charted that the record cannot defend (F641 accuracy).
Section GG usual performance captured across shifts (not most-independent or most-dependent).
New pressure injuries carry stage, measurements, and present-on-admission status (Section M / F686).
Restorative minutes and technique documented to support O0500 when a program is in place.
