General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 3.7
CVA / Stroke — Disease Overlay
Disease-specific skilled documentation for the post-stroke Part A rehabilitation stay — rehabilitation-nursing carryover across the deficit set (motor, sensory, swallow, communication, cognition, vision), secondary-prevention management, and complication surveillance (aspiration, DVT, depression, recurrent stroke). Layers on the Neurological reference. Post-stroke rehab is one of the most common skilled SNF stays.
Module code | SNF-OV-CVA |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Neurological (base) · Functional/Section GG · Restorative · Taste/Swallowing · Communication · Skilled-Daily · Anticoagulation overlay |
MDS section(s) | GG (self-care/mobility) · C (BIMS) · B (vision/hearing/speech) · O (therapy) · N (antithrombotic/secondary-prevention meds) · I (stroke) |
Skilled category (Ch. 8) | Rehabilitation nursing (deficit carryover) · observation & assessment of a recurrent stroke or complication · management & evaluation · teaching (secondary prevention) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: 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. |
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