← Document menu Nursing Home · DiraChart 1. Purpose and clinical relevance DiraChart Clinical Reference
Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.
.SENS_NEUROPATHY
Sensation: {light touch/protective — monofilament} by area, distribution {stocking-glove/dermatomal/hemibody}, vs prior {change}. Feet/skin {inspected/intact}, protective {footwear/offloading}, temperature safety {measures}. Skilled protective management required. Supports Section GG; goal {###}. (Skin/Diabetes references.)
.SENS_ACUTE
Acute sensory change: {ascending/level/hemibody}, associated {weakness/bowel-bladder}. Provider notified urgently; level documented; {imaging/stroke pathway}; representative notified. Neurologic emergency. Reassess {when}. Supports Section I. (Neuro reference.)
.SENS_INJURY
Injury from lost sensation: {burn/blister/breakdown} on insensate {area}, unfelt. Assessed/measured; cause {heat/footwear/pressure}; provider notified; treatment/protection intensified; care plan revised; skin section coded. Reassess {when}. (Skin reference.)
Section Navigation Part 12 of 15 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What to assess, technique, and required data 4. 3. Normal findings — documented with skill justification 5. 4. Abnormal findings — the necessity chain 6. 5. Skilled interventions and teaching 7. 6. Red flags — escalate / transfer 8. 7. Skilled-need justification (SNF) 9. 8. MDS & care-plan linkage 10. 9. Weak vs. strong documentation 11. 10. Audit and denial risks (Medicare Part A) 12. Smart phrases 13. Daily-note bank — routine skilled days 14. Daily-note bank — change-of-condition / at-risk days 15. 12. Sources and clinical references Previous Next 