Anticoagulation

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DiraChart Clinical Reference
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1. Purpose and clinical relevance

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9. Weak vs. strong documentation

Weak — does not survive

Why it fails

Strong — defensible

“Coumadin given.”

No INR, no target, no bleeding surveillance, no MDS support — the skilled monitoring is invisible.

The warfarin model note in §3: the INR against the target, the protocol-based dose decision, the bleeding surveillance, and the reason daily monitoring was skilled.

“No bleeding noted.”

No specifics of what was surveyed.

“No bruising, epistaxis, hematuria, or melena; no new interacting medications; fall precautions in place.”

“INR high.”

No value, no target, no protocol action, no monitoring.

“INR 5.2 (target 2.0–3.0), no active bleeding → warfarin held per protocol → provider notified; hold ± vitamin K and repeat INR ordered; bleeding precautions.”

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