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DiraChart Clinical Reference
Section NavigationPart 10 of 15PreviousNext 9. Weak vs. strong documentation
Weak — does not survive | Why it fails | Strong — defensible |
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“ADLs done. Total care.” | No item-level usual performance, no assist type/amount — Section GG and the function score unsupported. | The GG-capture model note in §3: item-level usual performance across shifts with assist level and device, and the GG0130/GG0170 linkage. |
“Transfers with assist.” | Ambiguous — supervision? partial? maximal? — not codable. | “Chair-to-bed transfers with a walker and supervision, consistent across shifts (coded supervision).” |
Best-episode captured | Coding the most-independent moment overstates function. | Capture usual (typical) performance across the window from all shifts/disciplines. |
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