DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.29
Ears / Hearing
Functional hearing, the external ear, and peripheral vestibular function. Routed here: functional hearing and hearing-aid use, the external ear and canal, cerumen impaction, otalgia, tinnitus, peripheral vertigo, and the vestibular contribution to balance. A central cause of vertigo — sudden, with other neurologic signs — routes to Neurological; communication accommodations are shared with Communication; vestibular fall risk is shared with Safety.
Communication (accommodations) · Safety (vestibular fall risk) · Neurological (central vertigo)
How to use this module
This module supplies the functional hearing and external-ear examination and the assessment of vertigo and hearing-aid use — with the skilled language that proves it took a licensed nurse. It is a home-health functional assessment, not an audiologic or otologic exam; vertigo with other neurologic signs is routed to Neurological as a possible stroke, and communication strategies are routed to Communication. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy.
