Hydration

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Trace DC100-12

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.

.HYD_IV

IV fluids: {fluid} at {rate} per order via a patent site; I&O {balance}, urine output {status}, membranes {moist}, turgor {status}, BP/HR {values}, orthostatic {status}. Overload watch: {edema/crackles/dyspnea none}. Covered skilled IV hydration; daily fluid assessment. Supports Section K; hydration goal {###}.

.HYD_DEHYDRATION

Dehydration: intake {reduced}, urine {dark/low output}, membranes {dry}, orthostatic drop {values}, {confusion}. IV fluids per order; I&O/vitals tracked; {renal/electrolyte labs}; provider/representative notified; fall precautions. Reassess {when}. Supports Section K/J.

.HYD_OVERLOAD

Overload risk (HF/renal): {edema/crackles/dyspnea}, balance {positive}. Fluids reviewed/adjusted per order; provider notified; volume reassessed; respiratory monitoring. Reassess {when}. (CHF overlay.)

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