COPD

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Trace DC60-12

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.

.COPD_DAILY

COPD recovery: RR {##} {pursed-lip/accessory}, SpO₂ {##}% on {O₂} within target {88–92%}, lungs {wheeze/air movement}, sputum {color/amount vs prior}, treatments {scheduled/PRN} tolerated, steroid taper {status}. Skilled respiratory observation required daily. Supports Section O; respiratory goal {###}.

.COPD_EXACERB

Exacerbation: dyspnea {increased}, RR {##}, {accessory}, SpO₂ {##}% (below target), {wheeze/diminished}, sputum {purulence change}. Bronchodilator + O₂ titration → SpO₂ {##}%. SBAR {time}; {neb/steroid/antibiotic/CXR} ordered; representative notified {time}. Reassess {when}. Supports Section O.

.COPD_TEACH

Inhaler technique: {MDI/spacer/DPI} return-demo {#/#} ({correction}); action plan (green/yellow/red) teach-back {##}%; oxygen safety reviewed. Covered skilled teaching to competence. Respiratory goal {###}.

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