Musculoskeletal

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Trace DC72-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Post-TKR recovery

Day 6: incision well-approximated, staples intact, no drainage/erythema, swelling improving with elevation/ice; NV intact; weight-bearing as tolerated with precautions; pain 3/10 with movement (from 6/10), full therapy participation; VTE prophylaxis given. Skilled post-surgical assessment required daily; supports Section GG/O/N.

Post-ORIF rehab carryover

Transfers/ambulation with the ordered assist and hip precautions maintained, restorative reinforcement with a CNA return-demo, pain controlled for participation, incision intact. Skilled evaluation and safe carryover required; supports Section GG and O0500.

Amputation recovery

Residual-limb incision intact, no drainage, shaping/wrapping per order, phantom/residual pain managed, transfers with the ordered assist. Skilled post-surgical assessment and rehabilitation nursing required; supports Section GG/O.

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