General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.3
Skin Integrity, Wounds & Pressure Injury
Facility-wide skin surveillance and skilled wound care — NPIAP staging, measurement, the present-on-admission (avoidable vs unavoidable) determination, weekly skin sweeps, the prevention plan, and MDS Section M accuracy — surveyed under F686, one of the most cited and litigated nursing-home domains.
Module code | SNF-SKIN |
|---|---|
Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Integumentary baseline · Nutrition · Continence · Peripheral Vascular · Diabetes overlay · Skilled-Daily |
MDS section(s) | M0100–M1200 (risk; pressure ulcers/injuries by stage; present-on-admission; other skin conditions; healing) · GG / immobility |
Survey F-tag(s) | F686 (skin integrity / pressure ulcers) · F684 · F687 (foot care) |
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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