Head Scalp

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Trace DC80-12

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.

.HEAD_POSTOP

Post-{craniotomy/neurosurgery} day {#}: incision {approximation/drainage/erythema/swelling}, {staples/drain}. Neuro: A&O×{#}, PERRL, {headache/nausea/drowsiness none}, strength {#/5}. Covered skilled incision care + neuro surveillance. Supports Section I; goal {###}. (Neuro reference.)

.HEAD_STRIKE

Post-head-strike surveillance: scalp {intact/hematoma/laceration}, neuro checks per protocol {results}, delayed-bleed watch ({headache/vomiting/drowsiness none}). On anticoagulant {y/n}. Reassess {when}. (Falls protocol.)

.HEAD_ICP

ICP/complication concern: {worsening headache/vomiting/drowsiness/pupil change/incision change}. Neuro + incision assessed; neurosurgery/provider notified urgently; {imaging}; representative notified; close neuro monitoring. Emergency. Supports Section I.

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