Post Surgical

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Trace DC102-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Post-op recovery, progressing

Day 5: incision well-approximated, no drainage/erythema, drain patent with decreasing output, pain controlled for full therapy, VTE prophylaxis given (calf clear), bowel returning, lungs clear (IS used), precautions/activity observed. Skilled post-surgical surveillance + rehab nursing required; supports Section GG/O/N.

Rehab-nursing + pain-enabled therapy

Transfers/mobility with the ordered assist and precautions maintained, restorative reinforcement delivered, pain controlled specifically to allow participation, incision intact. Skilled evaluation and safe carryover required; supports Section GG.

Post-abdominal-surgery recovery

Abdominal incision intact, bowel function returning with flatus, no distension, tolerating diet advance per order, ambulating per order. Skilled post-surgical surveillance (ileus/SSI) required; supports Section I.

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