DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Core Assessment Domain · 2.12
Psychosocial / Caregiver
Social support, caregiver capacity and strain, coping, resources, and the social determinants that shape a patient's safety and ability to follow the plan of care.
Psychiatric / Mental Health · Function (ADL / IADL) · Safety · Cognitive / Mental Status · General / Constitutional · Foundations apply to every visit.
How to use this module
This module supplies psychosocial and caregiver assessment and the skilled language that proves it required a licensed nurse — the support system, caregiver capacity and strain, coping, the social determinants of health, and the resource coordination the plan depends on. Mood and risk are assessed in Psychiatric / Mental Health, functional dependence in Function, and safety and the mandated reporting of abuse in Safety. Because the plan of care succeeds or fails on the strength of the patient's supports, this assessment is frequently the basis for management and evaluation of the plan. Each narrative is a structured example to be edited to the actual visit.
