General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 3.9
Post-Surgical / Orthopedic — Disease Overlay
Disease-specific skilled documentation for the post-operative Part A stay — incision and drain care, VTE-prophylaxis monitoring, pain control that enables therapy, surgical-precaution enforcement, and surveillance for the post-operative complications (infection, bleeding, VTE, ileus, dehiscence, atelectasis). Layers on the Musculoskeletal reference and applies to surgical recovery broadly. Post-surgical recovery is a leading skilled SNF stay.
Module code | SNF-OV-POSTOP |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Musculoskeletal (base) · Skin (incision/wound) · Pain · Lines/Drains/Devices · Functional/Section GG · Skilled-Daily · Anticoagulation overlay |
MDS section(s) | GG (self-care/mobility) · O (therapy; IV medication) · J (pain) · N (VTE prophylaxis) · I (surgical procedure) |
Skilled category (Ch. 8) | Observation & assessment of the post-surgical course · covered skilled procedures (incision/drain care; IV medication) · rehabilitation nursing · management & evaluation · teaching |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684 — secondary to the coverage analysis. |
How to use this module This is a disease OVERLAY: it layers disease-specific skilled documentation on top of the body-system reference named below. Use it with that system module, not instead of it. Every model note is a scaffold to edit to the shift and the resident’s orders; the universal writing rules live in Foundations and are not reprinted. Verify parameters and citations against the current source. |
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