Psychosocial Caregiver

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Trace DC90-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Psychosocial support of recovery

Mood stable (PHQ improving), engaged and motivated, participating fully in the skilled rehab/ADL program, support system involved, discharge caregiver identified. Skilled M&E to protect the skilled goals and coordinate discharge required; supports Section D/Q.

Caregiver teaching to competence

Discharge caregiver taught transfers and the medication schedule, return-demo 8/8 (2nd attempt), warning-sign teach-back 100%. Covered skilled caregiver teaching for a safe discharge; supports Section Q.

Adjustment support, progressing

Adjustment reaction to the illness being managed with counseling support and structured engagement, participation improving. Skilled observation and management to keep the skilled plan on track required; supports Section D.

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