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DiraChart Clinical Reference
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EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.
.NOSE_EPISTAXIS Epistaxis: {anterior/posterior}, volume {amount}, control {status}, anticoagulant {agent/held per parameters}. Pressure/airway management; vitals {trend}. SBAR to {provider}; {packing/cautery/labs}; representative notified. Reassess {when}. (Anticoag overlay.) Supports Section I. |
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.NOSE_DEVICE Nares care ({cannula/NG}): nares {intact/breakdown}, septum {status}, padding per plan, mucosa {moist}, device {patent/secured}. Skilled nares care to prevent pressure injury. Supports Section O/care-plan goal. |
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.NOSE_CSF Post-neurosurgery: new clear watery drainage {which nostril} — CSF-leak concern. Neurosurgery/provider notified urgently; HOB per order; no nose-blowing; drainage characterized; neuro monitored. Meningitis risk. Supports Section I. |
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