Safety

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Trace DC19-2

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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1. Purpose and clinical relevance

Safety is a core home-health responsibility and a frequent driver of injury and rehospitalization. Falls are the leading cause of injury in older adults, and a cluttered walkway, an unsteady gait on a new medication, an unsafe oxygen practice, or a disorganized medication regimen each create risk that a layperson may not recognize. Identifying hazards, screening fall risk, and mitigating both require nursing judgment.

The purpose of this module is to give clinicians the skilled framework and chartable language that demonstrate fall-risk assessment, home-hazard reduction, medication safety, and emergency-preparedness coordination were reasonable and necessary and required the skills of a licensed nurse. It is the primary home for safety assessment; functional mobility lives in Function, cognition in Cognitive / Mental Status, and medication-class-specific safety (anticoagulant bleeding, opioid sedation) in the relevant overlays and the Pain module.

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