Skin Pressure Injury

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Trace DC83-12

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.

.SKIN_SWEEP

Weekly skin assessment: skin {intact/see wound}, Braden {##} ({risk}); repositioning q{#}h, {surface} in use, heels floated, continence care timely. No new pressure injury. Supports Section M; skin care-plan goal {###}.

.SKIN_WOUND

{Etiology} {stage} at {site}: {L}×{W}×{D} cm (vs {prior}), {tunneling/undermining}, bed {##}% granulation/{slough/eschar}, exudate {amount/type}, periwound {status}, odor {y/n}, pain {##}. Ordered {dressing} performed, {technique}. POA {status}. Section M coded. Trajectory {improving/stalled/worsening}.

.SKIN_NEW

New {stage} pressure injury at {site} {measurements}, NOT present on admission (facility-acquired). POA documented; provider notified; treatment order {details}; prevention intensified ({repositioning/surface/nutrition}); Section M coded; care plan revised; avoidability: {avoidable/unavoidable} — rationale {…}.

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