General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.39
Female Reproductive System
Skilled documentation when the female reproductive system is the reason for or a factor in a Part A stay — post-gynecologic-surgery recovery (hysterectomy, prolapse repair, oncologic), post-operative vaginal bleeding and vaginal-cuff-dehiscence surveillance, and pessary management. Post-gyn-surgery skilled care is a genuine SNF scenario. Continence and perineal-skin detail route to Continence and External Genitalia.
Module code | SNF-FEMREPRO |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Continence/Catheter/UTI · Skin · External Genitalia · Skilled-Daily · Post-Surgical and Anticoagulation overlays |
MDS section(s) | M (perineal skin/wound) · H (continence) · I (gynecologic diagnoses; recent surgery) |
Skilled category (Ch. 8) | Covered skilled procedures (post-operative gynecologic care; pessary care) · observation & assessment of post-operative bleeding/complication · 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. |
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