General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.37
Allergic & Immunologic System
Skilled documentation when allergy or immune status is the reason for or a factor in a Part A stay — anaphylaxis and severe allergic-reaction recognition and management, immunosuppression (post-transplant, chemotherapy, or immunotherapy) with infection precautions, IVIG/immunotherapy administration, and severe drug reactions. Anaphylaxis and immunosuppressed infection are time-critical skilled scenarios.
Module code | SNF-ALLERGY |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Respiratory (airway) · Hematologic · Lines/Drains/Devices (IVIG) · Skilled-Daily · Sepsis overlay · Change of Condition |
MDS section(s) | O0110 (IVIG/IV medication; isolation) · N (immunosuppressants; relevant medications) · I (immunodeficiency; transplant; autoimmune disease; drug allergy) |
Skilled category (Ch. 8) | Observation & assessment of an allergic reaction / immunosuppressed infection status · covered skilled procedures (IVIG / immunotherapy / IV medication administration) · teaching |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Infection-control reference: F880 (protective precautions) — secondary to the coverage analysis. |
How to use this module Fill every model note and smart phrase with the shift’s actual values and the resident’s current orders — these are structured examples to edit, never phrases to copy. The universal writing rules in Foundations (the necessity sentence, quantified outcomes, teach-back, closed-loop coordination, MDS-supportive documentation, and care-plan linkage) apply throughout and are not reprinted here. Disease-specific days route to the overlays. Verify each threshold and citation against the current source before use. |
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