Peripheral Vascular

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Trace DC91-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Venous insufficiency + compression

Bilateral LE edema improved to 1+ (from 2+) with correct compression and elevation, pedal pulses palpable, skin with hemosiderin staining but intact, no calf tenderness/asymmetry. Skilled vascular assessment and compression evaluation required daily; supports Section J.

PAD perfusion monitoring

Affected foot with pulses per baseline, warm, intact color, brisk capillary refill, no rest pain or skin change, protective foot care in place. Skilled perfusion assessment required; supports Section I.

Resolving DVT on anticoagulation

Known DVT: calf swelling/tenderness improving, on the ordered anticoagulant with monitoring, no embolic signs, ambulating per order. Skilled surveillance and anticoagulation monitoring required; supports Section N. (Anticoag overlay.)

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