General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.2
Falls Management & Post-Fall Documentation
Fall-risk assessment, the individualized intervention plan, the immediate post-fall workup, the investigation and root-cause record, and MDS falls coding — the documentation surveyed under F689, the highest-frequency nursing-home citation.
Module code | SNF-FALLS |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Neurological · Musculoskeletal · Cognitive · Anticoagulation overlay · Skilled-Daily · Change of Condition |
MDS section(s) | J1700–J1900 (falls history; falls with injury) · GG (function) · N (anticoagulant) |
Survey F-tag(s) | F689 (free of accident hazards / adequate supervision / assistance devices) · F684 · F580 (notification) |
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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