DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.27
Head / Scalp
The cranium, scalp, face, and hair, and head-injury surveillance. Routed here: post-fall head-strike monitoring, scalp integrity (lacerations, lesions, infestation, seborrhea), headache as a presenting symptom, the temporal-artery region, and facial skin in general. Neurologic deficits route to Neurological; changes in mentation route to Cognitive/Mental Status; an anticoagulated head strike is shared with the Anticoagulation overlay; scalp skin and wounds are shared with Integumentary and Wounds.
This module supplies the structural head, scalp, and face examination and, critically, the post-fall head-injury surveillance that home-health patients on anticoagulants require — with the skilled language that proves it took a licensed nurse. Detailed cranial-nerve and motor findings are documented in Neurological; mentation changes in Cognitive; an anticoagulated head strike is escalated with the Anticoagulation overlay. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy.
