General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.34
Touch & Peripheral Sensation
Skilled documentation when sensation is the reason for or a factor in a Part A stay — peripheral neuropathy (diabetic or chemotherapy-induced), post-stroke or spinal-cord sensory loss, and the loss of protective sensation that drives skin breakdown, burns, and falls. A sensory deficit is a safety problem the skilled plan must actively manage. Foot-wound detail routes to Skin.
Module code | SNF-TOUCH |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Neurological · Skin · Diabetes overlay · Falls · Musculoskeletal · Skilled-Daily |
MDS section(s) | GG (function) · C (cognition) · I (neuropathy; spinal-cord injury; stroke) |
Skilled category (Ch. 8) | Observation & assessment of a sensory change/neuropathy · management & evaluation (protective care) · teaching (protective strategies) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684; skin F686 — 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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