General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.17
Genitourinary & Renal System
Skilled renal documentation for the Part A day — acute-kidney-injury recovery, chronic kidney disease and ESRD, dialysis coordination and access care, and renal fluid/electrolyte management. Proves the skilled renal observation, intake/output and electrolyte monitoring, and dialysis-related management that an unstable renal course requires daily. Catheter/UTI care routes to Continence.
Module code | SNF-RENAL |
|---|---|
Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Continence/Catheter/UTI · Cardiovascular · Nutrition · Skilled-Daily · Dialysis overlay · Change of Condition |
MDS section(s) | O0110 (dialysis) · N (medications) · K (nutrition — renal diet) · I (renal failure, ESRD) |
Skilled category (Ch. 8) | Observation & assessment of an unstable renal/fluid-electrolyte status · covered skilled procedures (dialysis-access care; IV medication) · teaching · management & evaluation |
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. |
|---|