Nose Sinuses

Printing and PDF export are disabled for this protected preview. Continue reading inside the DiraChart reader.

Trace DC8-22

DiraChart Clinical Reference
Protected section 22 of 25
← Document menu
Home Care · DiraChart

1. Purpose and clinical relevance

DiraChart Clinical Reference

Section NavigationPart 22 of 25PreviousNext

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.

.NOSE_PATENCY

Nares [patent/obstructed] bilaterally; drainage [absent/clear/purulent/bloody]; sinus tenderness [none/described]; [unchanged] from baseline.

.NOSE_EPISTAXIS

Epistaxis [anterior/posterior], volume [estimate], controlled after [time] firm pressure [or not controlled]; anticoagulant [agent]; BP [value]; [action].

.NOSE_CANNULA

Skin under/around cannula — nares, columella, behind ears — [intact/erythema/breakdown] at [flow] L/min; padding [in place]; [action] (O2 mgmt in Respiratory).

.NOSE_SINUS

Sinus symptoms: facial [pain/pressure/tenderness], drainage [character], fever [yes/no], swelling [none/described]; assessment [described]; [action].

.NOSE_SMELL

Smell [at baseline/new loss]; effect on appetite/safety [described]; [action] (see Taste/Swallowing).

.NOSE_TEACH

Taught [epistaxis control/cannula skin care/humidification/sinus self-care]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].

.NOSE_NOTIFY

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

Section NavigationPart 22 of 25PreviousNext