Eyes Vision

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Trace DC86-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Post-cataract care

Day 3: operative eye white/quiet, no abnormal discharge, mild scratchiness only, antibiotic/steroid drops on the ordered taper administered with correct technique, shield for sleep, vision improving. Covered daily skilled eye care with complication surveillance; supports Section B.

Post-retinal-repair positioning

Day 2: surgeon-ordered face-down positioning maintained and tolerated with skin monitored, drop regimen administered, operative eye without new pain/discharge. Skilled enforcement/evaluation of positioning and drops required; supports the eye goal.

Corneal protection, neuro resident

Impaired blink/closure post-stroke — lubrication and taping per order, eye without abrasion signs, safe mobility assisted. Skilled corneal protection required; supports Section B.

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