Musculoskeletal

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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 — the parent and overlay phrases. Chart only the elements actually assessed.

.MSK_ASSESS

Skilled MSK assessment: strength [grades by group, 0–5], [symmetric/baseline]; ROM [joint] [arc/restriction]; joints [condition]; pain [score] with movement.

.MSK_GAIT

Gait [pattern] with [device] × [distance], [steady/with guarding/loss of balance]; balance [finding]; device fitted correctly and used [safely/with errors corrected].

.MSK_PRECAUTION

Post-operative [surgery] precautions [intact/breached]: [specific restrictions]; weight-bearing status [order] verified and observed.

.MSK_FUNCTION

Transfers [type] with [assist level]; functional status [stable/progressing/declined] from [baseline]; impact on ADLs [described].

.MSK_TEACH

Taught [HEP/precautions/safe transfers]; [patient/caregiver] return-demonstrated [result]; remaining gaps [none/described].

.MSK_NOTIFY

Provider/PT notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [parameter] next visit.

.MSK_NECESSITY

Skilled [assessment/teaching] required to [reason]; measurable effect: [functional change or plan decision].

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