Eyes Vision

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Trace DC39-22

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.

.EYE_VISION

Functional vision [near/distance result] with [correction]; new change [none/described — onset/pattern]; [unchanged] from baseline.

.EYE_EXTERNAL

External eye: lids/conjunctiva/sclera [clear/findings]; discharge [none/described]; pupils grossly [equal/reactive]; [unchanged].

.EYE_ACUTE

Acute change: [sudden painless loss / painful red eye with halos / flashes-floaters-curtain / diplopia with neuro signs]; assessment [described]; [emergency escalation].

.EYE_DROPS

Observed [drop/ointment] technique: hygiene, lower-lid pocket, tip not touched, spacing; technique [correct/corrected]; adherence [described].

.EYE_RETINOPATHY

Retinopathy surveillance: last dilated exam [date]; status [current/overdue]; reinforced schedule (see Diabetes/Hypertension overlays).

.EYE_TEACH

Taught [drop technique/warning signs/adherence/low-vision safety]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].

.EYE_NOTIFY

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

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