Skilled Daily Documentation

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Trace DC55-15

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Subjective — ask

  • New or changed symptoms since the last shift; the resident’s report of the condition being managed.
  • Pain (PQRST, or PAINAD for non-communicative residents) and its effect on participation and sleep.
  • Tolerance of the skilled service (the procedure, the therapy, the teaching) and any barriers.
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