Falls Management

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Trace DC75-12

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.

.FALL_RISK

Fall-risk plan reviewed: {alarm status}, {footwear}, call light {status}, toileting {schedule}, bed low/locked. Risk factors: {list}. No fall this shift. RN surveillance required given {dx/anticoagulant}. Care-plan falls goal {###}.

.FALL_EVENT

{Witnessed/Unwitnessed} fall {time}, {location/position}. Injury survey: {findings}. Neuro checks: {schedule/results}. Vitals {values}, pain {##}. On {anticoagulant?}. SBAR to {provider} {time}; orders {details}; representative notified {time}. New intervention: {intervention}. Section J coded. Root-cause review initiated.

.FALL_NEURO

Post-fall neuro checks per protocol: PERRL, A&O×{#}, strength {#/5} symmetric, speech clear, no new deficit, no headache/vomiting/drowsiness. Next check {time}. Escalate for {red-flag list}.

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