Psychosocial Caregiver

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Trace DC90-12

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.

.PSY_STATUS

Psychosocial: mood {stable/PHQ trend}, engagement {level}, participation in skilled plan {status}. Support system/discharge caregiver {identified}. M&E required to keep psychosocial factors from undermining skilled goals. Supports Section D/Q; goal {###}.

.PSY_DECOMP

Psychosocial decompensation: {mood/engagement change} with {refusal/reduced intake} over {time} — stalling the skilled plan. Mood screen updated; non-pharm support/re-engagement intensified; provider + social services notified; plan re-evaluated. Reassess {when}. SCSA {y/n}. Supports Section D/Q.

.PSY_CAREGIVER

Caregiver teaching ({caregiver}): {task} return-demo {#/#}; warning-sign teach-back {##}%; confidence {level}. Skilled teaching to competence for safe discharge. {Capacity gap → social services} if applicable. Supports Section Q.

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