Foundations

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Trace DC6-20

DiraChart Clinical Reference
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1.1 Why “WNL” alone fails

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1.6 Quantified outcomes

Medicare auditors cannot evaluate qualitative claims. “Patient improved,” “better today,” “tolerated treatment well” are clinical impressions, not outcomes. The visit needs a measurable trajectory.

The principle

Every skilled intervention should produce a documented numeric outcome — a vital-sign change, a distance, a percentage, a count, or a grade.

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