Female Reproductive

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Trace DC64-12

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.

.FREPRO_POSTOP

Post-{hysterectomy/GYN surgery} day {#}: vaginal bleeding {amount vs expected}, incision {clean/dry/staples}, fever {none}, bowel {sounds/diet}, VTE prophylaxis {given}. Cuff-dehiscence watch {none}. Skilled post-operative surveillance. Supports Section I; goal {###}. (Anticoag overlay.)

.FREPRO_HEMORRHAGE

Post-op vaginal hemorrhage/cuff-dehiscence concern: {heavy bleeding/clots/gush}, {after straining}. At rest; vitals monitored; surgeon/provider notified urgently; {evaluation/emergency measures}; anticoagulation reviewed; representative notified. Reassess {when}. Supports Section I.

.FREPRO_PESSARY

Pessary: in place, fit {comfortable}, vaginal/perineal skin {intact/erosion/discharge}, cleaned per {schedule}. Skilled pessary assessment/care. Supports Section I; goal {###}.

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