Communication

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1. Purpose and clinical relevance

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General Section

SKILLED DOCUMENTATION GUIDELINES — EXPANDED

DiraChart · Clinical Reference · Read-only baseline inherited by all agencies

Core Assessment Domain · 2.9

Communication

Speech, language, functional hearing and vision, and health literacy as they affect the patient's ability to understand, be understood, and participate safely in care.

Module code

DOM-COMMUNICATION

Version

1.0 · Population: Adult · Authoring level: DiraChart

Used alongside

Ears / Hearing · Eyes / Vision · Neurological · Cognitive / Mental Status · Taste / Swallowing · Foundations apply to every visit.

How to use this module

This module supplies communication-ability assessment and the skilled language that proves it required a licensed nurse — speech and language, functional hearing and vision for care, health literacy, and the accommodations that make teaching and consent valid. The hearing examination lives in Ears / Hearing, the vision examination in Eyes / Vision, the aphasia and dysarthria neurologic basis in Neurological, and cognitive-communication in Cognitive / Mental Status. Because communication underlies every teaching and consent interaction, this assessment shapes the entire plan. Each narrative is a structured example to be edited to the actual visit.

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