DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Core Assessment Domain · 2.1
General / Constitutional
General appearance, level of distress, and constitutional symptoms — the overall clinical gestalt that frames every visit and the symptom clusters that signal early systemic illness.
Vital Signs (Core Domain) · Nutrition (Core Domain) · every Body System reference · Foundations apply to every visit.
How to use this module
This module supplies the general survey and constitutional review that open every visit and the skilled language that proves the clinical gestalt required a licensed nurse. It owns the overall appearance, distress level, and constitutional symptom review; system-specific findings are assessed and documented in the relevant Body System module. Each narrative is a structured example to be edited to the actual visit.
