General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.28
Ears & Hearing
Skilled documentation when the ear is the reason for or a factor in a Part A stay — post-operative otologic/ENT surgery (mastoidectomy, tympanoplasty, cochlear implant), acute vertigo with its fall risk, acute infection, and hearing loss that impairs the skilled plan by blocking teaching and participation. Balance and communication make the ear a genuine skilled concern.
Module code | SNF-EARS |
|---|---|
Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Neurological (vestibular) · Falls (vertigo) · Communication · Cognitive · Skilled-Daily · Post-Surgical overlay |
MDS section(s) | B0200 (hearing) · B0300 (hearing aid) · I (ear diagnoses; recent otologic surgery) |
Skilled category (Ch. 8) | Observation & assessment (post-operative course; vertigo/balance; acute change) · covered skilled procedures (post-operative ear care) · teaching (post-operative precautions; communication strategies) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684 — 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. |
|---|