General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 3.8
Dementia / BPSD — Disease Overlay
Disease-specific skilled documentation for the dementia resident on a Part A stay — recognizing delirium superimposed on dementia, skilled non-pharmacologic management of new or dangerous behavioral and psychological symptoms (BPSD), and safety. Layers on the Cognitive and Behavioral references. Dementia alone is not a skilled qualifier; the skilled element is a superimposed acute change, delirium, or a skilled comorbidity.
Module code | SNF-OV-DEM |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Cognitive (base) · Behavioral · Psychosocial · Falls · Skilled-Daily · Change of Condition |
MDS section(s) | C (BIMS; delirium/CAM) · D (mood) · E (behavior) · I (dementia) |
Skilled category (Ch. 8) | Observation & assessment of delirium-superimposed-on-dementia / an acute change · management & evaluation (behavioral plan) · teaching (caregiver) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care and behavioral references: F684/F742 — secondary to the coverage analysis. |
How to use this module This is a disease OVERLAY: it layers disease-specific skilled documentation on top of the body-system reference named below. Use it with that system module, not instead of it. Every model note is a scaffold to edit to the shift and the resident’s orders; the universal writing rules live in Foundations and are not reprinted. Verify parameters and citations against the current source. |
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