General Constitutional

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Trace DC54-12

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.

.GEN_SURVEIL

Whole-person surveillance: afebrile/{T ##}, energy {baseline}, intake {##}%, weight {trend}, participation {status}. Multi-problem plan reviewed; unskilled care achieving purpose. Skilled systemic observation + M&E required daily. Supports Section K/I; goals {###}.

.GEN_SEPSIS

Sepsis surveillance: T {##}, HR {##}, RR {##}, {new confusion}, source {wound/urinary/resp}. Sepsis pathway initiated; SBAR {time} with the constitutional picture; {labs/cultures/evaluation}; representative notified; close monitoring. Reassess {frequency}. Supports Section I.

.GEN_DECLINE

Generalized decline: intake/energy/participation {trend}, weight {loss}, no single cause. Multi-problem plan re-evaluated; provider/dietitian notified; reversible-cause workup ordered; goals-of-care revisited; care plan revised. Reassess {when}. Supports Section K.

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