General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.27
Eyes & Vision
Skilled documentation when the eye is the reason for or a factor in a Part A stay — post-operative ophthalmic surgery (cataract, retinal, glaucoma, corneal), the eye-drop regimen and required positioning, acute vision change, and eye care for the dependent or neurologically impaired resident. Post-eye-surgery skilled care is a genuine SNF scenario.
Module code | SNF-EYES |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Neurological (visual fields/stroke) · Skilled-Daily · Change of Condition · Post-Surgical overlay |
MDS section(s) | B0100 (comatose) · B1000 (vision) · I (eye diagnoses; recent ophthalmic surgery) |
Skilled category (Ch. 8) | Covered skilled procedures (post-operative eye care / ophthalmic medication per order) · observation & assessment of an acute vision change or post-operative complication · teaching (eye-drop technique; post-operative positioning) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684 — secondary to the coverage analysis. |
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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