External Genitalia

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Trace DC37-22

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.

.EGEN_CONSENT

Perineal/genital skin assessment performed with consent, privacy, and chaperone per policy.

.EGEN_SKIN

Perineal/genital skin [intact/erythema/denudation/breakdown]; moisture [controlled/uncontrolled]; [unchanged/changed] from baseline.

.EGEN_DIFF

Determination: [incontinence-associated dermatitis — diffuse, moisture pattern, folds] vs [pressure injury — localized over bony prominence, staged]; treatment [barrier/offloading]; [action] (see Wounds).

.EGEN_WOUND

Perineal/genital wound [location/size/depth/tissue/exudate]; stage [per Wounds]; trajectory [described]; [action].

.EGEN_NECRO

Necrotizing-infection screen: pain out of proportion [yes/no], discoloration/necrosis [none/described], crepitus [yes/no], systemic toxicity [none/described]; assessment [none/Fournier concern]; [action].

.EGEN_TEACH

Taught [perineal care/barrier application/moisture management/warning signs/device-site care]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].

.EGEN_NOTIFY

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

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