Wounds Pressure Injury

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Trace DC28-22

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.

.WND_ASSESS

Skilled wound assessment: [location] [etiology] wound, Stage [x]; [L×W×D cm] with [undermining/tunneling]; bed [granulation/slough/eschar %]; exudate [amount/type], [odor]; periwound [condition]; pain [score].

.WND_TREND

Compared to [prior dimensions] on [date]: dimensions [decreased/stable/increased]; trajectory [improving/stalled/declining]; plan [continued/revised].

.WND_DRESS

Cleansed per order with [solution]; [primary/secondary dressing] applied; offloading/compression [device] in place and effective; next change [schedule].

.WND_INFECT

Infection surveillance: [erythema width], [warmth], [exudate], [odor], [systemic signs]; assessment [local/spreading/systemic]; [action/notification].

.WND_TEACH

Taught [repositioning/offloading/dressing protection/infection signs]; [patient/caregiver] return-demonstrated [result]; remaining gaps [none/described].

.WND_NOTIFY

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

.WND_NECESSITY

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

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