Safety

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Trace DC19-23

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 — disease-overlay smart phrases.

.SAFE_NORMAL

Skilled safety assessment: fall risk {low/mitigated}, gait {steady/device}; home {no hazards/addressed}; meds stored safely, organized, reconciled, no high-risk errors; emergency prep adequate (phone, contacts, detectors, can summon help); no abuse/neglect indicators. RN judgment applied to screen and mitigate hazards given {dx}. Continued skilled monitoring indicated.

.SAFE_FALL

Fall hx {#/timeframe}; gait/balance {steady/unsteady}; orthostatic {pos/neg}; vision {ok/impaired}; footwear {appropriate/unsafe}; polypharmacy {#}; environment factors {...}; screen {low/elevated}.

.SAFE_HOME

Hazards by area: entry {...}; living {rugs/clutter/cords}; bedroom {...}; bathroom {grab bars/mat}; kitchen {...}; lighting {adequate/poor}; stairs/railings {...}; addressed {...}.

.SAFE_MEDS

Reconciled vs order; storage {safe/unsafe}; organization {system/none}; high-risk meds {#}; duplications {y/n}; expired {y/n}; flagged to provider {...}.

.SAFE_PREP

Phone {working}; contacts {posted}; smoke/CO detectors {functioning}; evacuation {able/plan}; oxygen safety {verified}; equipment backup {plan}; can summon help {y/n}.

.SAFE_TEACH

Reviewed {fall-prevention/med safety/emergency procedures/oxygen safety} with {pt/cg}; method {teach-back/return-demo}; mastery {##}%.

.SAFE_COORD

Provider notified at {time} re {fall/hazard/med error/abuse concern}; reported {content}; order received {PT/DME/plan}; {mandated report filed}; reassessment {when}.

.SAFE_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.

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