Post Surgical

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Trace DC102-12

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.

.POSTOP_DAY

Post-{procedure} day {#}: incision {approximation/drainage/erythema}, drain {output/patency}, pain {##} {controlled for therapy}, VTE prophylaxis {given, calf clear}, bowel {returning}, lungs {clear/IS used}, precautions {list} maintained. Skilled post-surgical surveillance + rehab nursing. Supports Section GG/O/N; goal {###}.

.POSTOP_SSI

SSI concern: incision {spreading erythema/warmth/purulence}, {fever}. Provider notified; culture/antibiotics ordered; dressing changed; limb/systemic reassessed; care plan revised; representative notified. Reassess {when}. (Skin/Sepsis references.) Supports Section I/N.

.POSTOP_VTE

Post-op VTE/bleeding: {unilateral calf swelling/warmth} (measured) or {excessive bleeding/falling Hgb}. Provider notified; {Doppler/labs}; prophylaxis/anticoagulation reviewed; embolic/hemodynamic monitoring; representative notified. Reassess {when}. Time-critical. (Anticoag/PV.)

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