General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.30
Nose & Sinuses
Skilled documentation when the nose is the reason for or a factor in a Part A stay — epistaxis management (especially on anticoagulation), post-nasal/sinus surgery care and packing, nasogastric-tube and nasal-cannula nares care, and post-neurosurgical CSF-rhinorrhea surveillance. Anticoagulated epistaxis and airway concerns make the nose a genuine skilled focus.
Module code | SNF-NOSE |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Respiratory · Lines/Drains/Devices (NG) · Nutrition (NG feeding) · Skilled-Daily · Anticoagulation overlay |
MDS section(s) | I (nasal/sinus diagnoses; recent surgery) · O0110 (oxygen) · K (NG feeding routes to Nutrition) |
Skilled category (Ch. 8) | Observation & assessment (epistaxis; post-operative; CSF leak) · covered skilled procedures (nasal packing/nares care; NG-related nares care) · teaching |
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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