Neurological

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Trace DC20-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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8. Interventions performed

Document the skilled interventions delivered this visit; each should connect to a finding and carry a reassessment in Section 10.

  • Neurologic assessment with a stroke screen and comparison to the neurologic baseline.
  • Acute-stroke recognition and immediate emergency activation, documenting the last-known-well time — the treatment window is time-critical.
  • Seizure assessment with seizure-safety measures and emergency activation for a prolonged seizure or status.
  • Coordination of evaluation and referral, and management of neurologic-medication adherence and effects.
  • Fall-risk and safety mitigation for neurologic deficits (with Safety and Function).
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