General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.21
Cognitive & Mental Status
Skilled documentation of cognition for the Part A day — delirium recognition against the dementia baseline, acute mental-status change, the BIMS/CAM data the MDS needs, and the safety implications. Distinguishing new delirium from a chronic baseline is a high-value skilled service and a frequent early sign of a treatable acute illness.
Module code | SNF-COG |
|---|---|
Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Neurological · Behavioral · General/Constitutional · Continence (UTI) · Skilled-Daily · Change of Condition · Dementia overlay |
MDS section(s) | C (BIMS; signs/symptoms of delirium / CAM) · D (mood) · I (dementia, delirium) |
Skilled category (Ch. 8) | Observation & assessment of an unstable cognitive status · management & evaluation · teaching |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684 — secondary to the coverage analysis. |
How to use this module Fill every model note and smart phrase with the shift’s actual values and the resident’s current orders — these are structured examples to edit, never phrases to copy. The universal writing rules in Foundations (the necessity sentence, quantified outcomes, teach-back, closed-loop coordination, MDS-supportive documentation, and care-plan linkage) apply throughout and are not reprinted here. Disease-specific days route to the overlays. Verify each threshold and citation against the current source before use. |
|---|