Skilled Daily Documentation

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Trace DC55-22

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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12. Red flags and emergency escalation

Escalation follows the resident’s orders and facility policy; the following are representative. Domain-specific red flags live in each clinical reference.

🚩 Red flags — escalate / transfer

Chest pain or suspected ACS (diaphoresis, dyspnea, radiation) — activate EMS/transfer per policy; administer prescribed nitroglycerin per order while awaiting transport. Do not delay transfer to complete repeated doses.

Acute respiratory distress, SpO₂ persistently below the ordered threshold unresponsive to intervention, or new stridor — emergency evaluation/transfer; tracheostomy obstruction → emergency airway per protocol + transfer.

New focal neuro deficit / positive BE-FAST — activate the stroke/transfer pathway (time-critical, especially on anticoagulation).

Post-fall on an anticoagulant with any new headache, vomiting, confusion, drowsiness, unequal pupils, or focal deficit — transfer (delayed intracranial bleed).

Sepsis signs — fever/hypothermia, hypotension, new confusion, tachypnea with an infectious source — escalate/transfer per the sepsis pathway.

Major bleeding (GI bleed, severe epistaxis, hematuria with clots, head injury) or thromboembolic signs on an anticoagulant — transfer per severity.

Suspected fracture after a fall (shortened/externally rotated limb, unable to bear weight) — immobilize and transfer.

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