DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.22
Musculoskeletal
Bones, joints, muscles, and mobility. Diagnoses commonly routed here: osteoarthritis and rheumatoid arthritis, post-operative joint replacement (total hip and knee), fractures and post-fracture recovery, osteoporosis, compression fractures, gait and balance disorders, contractures, and generalized weakness or deconditioning. Falls from environmental or cognitive causes are routed to Safety; neurogenic gait and sensory causes to Neurological.
This module supplies the complete musculoskeletal examination — strength, range of motion, gait, balance, joints, and post-operative orthopedic status — and the skilled language that proves it required a licensed nurse. It coordinates closely with physical therapy; nursing documents the assessment, the skilled teaching, and the management of the plan, and cross-references PT for the therapy plan. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy.
