CVA Stroke

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Trace DC84-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Post-stroke rehab carryover

Day 8: left arm 4/5 (from 3/5), rehab-nursing reinforcement with CNA return-demo, swallowing safe on the ordered texture with precautions, communication effective, secondary prevention in place (BP at goal, antiplatelet given no bleeding, statin continued). Skilled rehab nursing + surveillance required; supports Section GG/C/N.

Secondary prevention + surveillance

BP at the post-stroke goal, anticoagulant for the cardioembolic stroke given with bleeding surveillance, no aspiration/DVT signs, mood screened with support, no new deficit. Skilled management and surveillance required; supports Section N. (Anticoag overlay.)

Deficit-specific carryover

Communication and swallowing plans carried over with the established methods, function improving per Section GG, therapy coordinated. Skilled rehabilitation nursing required; supports Section GG. (Restorative/Communication/Swallowing.)

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