General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 3.10
Sepsis / Urosepsis — Disease Overlay
Disease-specific skilled documentation for sepsis on a Part A stay — early recognition of sepsis from a urinary (urosepsis), respiratory, wound, or line source; the surveillance and coordinated management of an evolving septic course; and the intensive skilled care of post-sepsis recovery. Layers on the General/Constitutional reference and the source’s reference. Sepsis recovery is a strong skilled qualifier and a major readmission driver.
Module code | SNF-OV-SEP |
|---|---|
Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | General/Constitutional (base) · Continence (urosepsis) · Respiratory · Skin (wound) · Lines/Drains/Devices · Vital Signs · Skilled-Daily · Change of Condition |
MDS section(s) | I (sepsis; the source infection) · O0110 (IV medication; isolation) · N (antibiotics) · K (nutrition/hydration) |
Skilled category (Ch. 8) | Observation & assessment of an unstable septic status · covered skilled procedures (IV antibiotics/fluids) · management & evaluation · teaching |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Infection-control and quality references: F880/F684 — secondary to the coverage analysis. |
How to use this module This is a disease OVERLAY: it layers disease-specific skilled documentation on top of the body-system reference named below. Use it with that system module, not instead of it. Every model note is a scaffold to edit to the shift and the resident’s orders; the universal writing rules live in Foundations and are not reprinted. Verify parameters and citations against the current source. |
|---|