Vital Signs

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Trace DC56-12

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.

.VS_SURVEIL

Parameter-based vitals: T {##}, HR {##}, RR {##}, BP {##}/{##} (parameters {…}), SpO₂ {##}% on {O₂}, pain {##}. Trend vs prior {stable/change}. Interpreted for {primary dx}; part of the daily skilled need. Supports the observation basis; goal {###}.

.VS_TREND

Deteriorating trend over {#} checks: HR {##→##}, RR {##→##}, T {##→##}, BP {##→##} — concerning for {process}. Focused assessment; SBAR {time} with the trend; {labs/orders}; representative notified; closer monitoring. Reassess {frequency}.

.VS_PARAM

{Value} outside notify parameter {threshold} with {symptom}. Interpreted in context ({med/intake/orthostasis}); provider notified with value + context; {orders}; {fall precautions/monitoring}. Reassess {when}.

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