Restorative Nursing

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Trace DC49-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Ambulation program

Ambulated 75 ft with a rolling walker and contact-guard ×1, 20 min, 6/7 days per program, tolerated (SpO₂ 96%). RN evaluation confirms the maintenance goal is met; supports O0500 walking-training and Section GG. Next re-eval dated.

ROM + splint program

Passive/active-assisted ROM to bilateral UE 15 min and resting hand splint per schedule with skin checks, no contracture progression. RN evaluation confirms decline prevented; supports O0500 (ROM, splint/brace).

Restorative dining

Restorative dining program: cueing and adaptive utensil use at meals, 20 min, self-feeding maintained. RN evaluation confirms the eating goal maintained; supports O0500 (eating/swallowing) and Section GG.

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