General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 3.4
Hypertension — Disease Overlay
Disease-specific skilled documentation for blood-pressure management within a Part A stay — parameter-based BP monitoring, antihypertensive titration and tolerance, orthostatic surveillance, and hypertensive urgency/emergency recognition. Layers on the Cardiovascular reference. Usually a contributing skilled element rather than a standalone qualifier.
Module code | SNF-OV-HTN |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Cardiovascular (base) · Vital Signs · Neurological · Genitourinary/Renal · Skilled-Daily · Change of Condition |
MDS section(s) | N (antihypertensive medications) · I (hypertension) · related cardiac/renal items |
Skilled category (Ch. 8) | Observation & assessment of an unstable blood-pressure status · management & evaluation (antihypertensive titration) · teaching · covered skilled procedures (IV antihypertensive, when ordered) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684 — secondary to the coverage analysis. |
How to use this module This is a disease OVERLAY: it layers disease-specific skilled documentation on top of the body-system reference named below. Use it with that system module, not instead of it. Every model note is a scaffold to edit to the shift and the resident’s orders; the universal writing rules live in Foundations and are not reprinted. Verify parameters and citations against the current source. |
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