General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.26
Psychosocial & Caregiver
Skilled documentation of the psychosocial factors that drive or complicate a Part A stay — mood and adjustment affecting participation and recovery, refusal or disengagement that stalls the skilled plan, caregiver-capacity assessment, and teaching a caregiver to competence for a safe discharge. Psychosocial decompensation is a real skilled scenario, and caregiver training is itself a covered service.
Module code | SNF-PSYCH |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Cognitive · Behavioral · Functional / Section GG · Nutrition · Skilled-Daily · Change of Condition · Dementia overlay |
MDS section(s) | D (mood — PHQ) · F (preferences/customary routine) · Q (participation; goals; discharge planning) · I (depression, adjustment disorder) |
Skilled category (Ch. 8) | Management & evaluation of the plan (integrating psychosocial factors that affect recovery) · teaching & training (caregiver to competence) · observation & assessment of a mood/engagement change affecting the skilled course |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Medically-related social services and behavioral-health references (F745, F740–F742) — 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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