Hematologic

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Trace DC26-6

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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4. Normal findings

“Normal/at-baseline” means there is no new bleeding, anemia, or infection sign, and any chronic hematologic condition is stable against the laboratory trend. Each line states the finding, the comparison to baseline, and the skilled reason a nurse was required — a bare “no bleeding” does not qualify.

  • Conjunctivae and nail beds pink; no new exertional fatigue, dyspnea, or dizziness suggesting anemia.
  • No new bruising or petechiae; no gum, nasal, urinary, or gastrointestinal bleeding.
  • No stool-color change or other sign of occult bleeding.
  • No signs of deep vein thrombosis or pulmonary embolism where a risk exists.
  • No fever or infection sign, including in an immunosuppressed patient at the current baseline.
  • Where applicable, no transfusion reaction and a stable post-transfusion status.
  • A chronic hematologic condition stable against the laboratory trend, with the plan appropriate to continue.
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