Safety

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Trace DC19-7

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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5. Abnormal findings

Abnormal findings and what they may signal — each warrants Mode B focused documentation and, where parameters are met, intervention and notification:

  • Elevated fall risk — recent falls, an unsteady gait, orthostatic symptoms, polypharmacy, or impaired vision.
  • Home hazards — clutter, throw rugs, poor lighting, unsafe stairs or bathroom, or cords in walkways.
  • Medication-safety problems — unsafe storage, disorganization, errors or duplications, high-risk combinations, or expired medications.
  • Inadequate emergency preparedness — no working phone, missing or non-functioning detectors, an inability to summon help or evacuate, or unsafe oxygen practices.
  • Wandering or elopement risk in a cognitively impaired patient.
  • Indicators of abuse, neglect, or self-neglect.
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