Female Reproductive

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Trace DC18-22

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — not duplicate — the parent and overlay phrases. Chart only the elements actually assessed.

.FREPRO_CONSENT

Female GU assessment performed with consent, privacy, and chaperone per policy.

.FREPRO_BLEED

Vaginal bleeding [none/described]; postmenopausal bleeding [none/present — malignancy until excluded]; discharge [none/described]; [action].

.FREPRO_PAIN

Pelvic pain [none/described], acuity [chronic/acute], fever [value]; assessment [none/PID-abscess-torsion concern]; [action].

.FREPRO_POSTOP

Post-op gyn site/vaginal cuff [healing/complication]; bleeding [none/described]; infection [none/described]; dehiscence [none/concern]; [action].

.FREPRO_PESSARY

Pessary [in place/removed]; comfort [described]; erosion/retention [none/described]; discharge [none/foul]; care [per plan]; [action].

.FREPRO_TEACH

Taught [post-op care/PMB reporting/pessary care/pelvic-floor/emergency signs]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].

.FREPRO_NOTIFY

Provider notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [parameter] next visit.

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