Sleep

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Trace DC42-23

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — not duplicate — disease-overlay smart phrases.

.SLP_NORMAL

Skilled sleep assessment: ~{#} hrs, acceptable latency, {few} awakenings, restorative; no excessive daytime sleepiness; contributing-factor review unremarkable; SDB screen negative; [sleep aid safe/effective]; supports function/mood/safety. RN judgment applied to analyze contributors and evaluate aid safety given {dx}. Continued skilled monitoring indicated.

.SLP_HISTORY

Total sleep {#} hrs; latency {#} min; awakenings {#} due to {pain/nocturia/dyspnea/anxiety}; early waking {y/n}; daytime sleepiness {y/n}; naps {#}.

.SLP_SDB

Snoring {y/n}; witnessed apneas {y/n}; gasping {y/n}; morning headache {y/n}; daytime sleepiness {y/n}; STOP-Bang {score}; screen {neg/pos}.

.SLP_AID

Sleep aid {drug/dose/timing}; effect {effective/ineffective}; next-day grogginess/unsteadiness {y/n}; fall risk {y/n}; flagged {y/n}.

.SLP_SKILL

Analyzed contributors {...}; coordinated {pain/dyspnea/nocturia/mood}; reviewed sleep-aid safety; screened SDB; CPAP adherence {data}; reinforced sleep hygiene.

.SLP_TEACH

Reviewed sleep hygiene, sleep-aid safety, {CPAP use} with {pt/cg}; method {teach-back/return-demo}; mastery {##}%.

.SLP_COORD

Provider notified at {time} re {sleep-aid risk/SDB/nocturnal symptoms}; reported {content}; order received {referral/deprescribe/volume plan}; reassessment {when}.

.SLP_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.

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