DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.28
Eyes / Vision
Functional vision and the external eye. Routed here: functional visual acuity, external-eye and conjunctival conditions, gross pupillary findings, ocular-medication administration, and the recognition of acute ocular emergencies and chronic ocular disease in the home. Cranial-nerve and visual-field deficits with other neurologic signs route to Neurological; low-vision fall risk is shared with Safety; diabetic and hypertensive retinopathy surveillance is shared with the Diabetes and Hypertension overlays.
This module supplies the functional vision and external-eye examination, ocular-medication management, and the recognition of sight-threatening emergencies — with the skilled language that proves it took a licensed nurse. It is a home-health functional assessment, not an ophthalmologic exam; new visual deficits with other neurologic signs are routed to Neurological, and systemic ocular disease control is routed to the relevant overlays. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy.
