General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.24
Sleep
Skilled documentation when sleep drives or complicates a Part A stay — CPAP/BiPAP management for sleep-disordered breathing, a sleep-wake disruption that signals delirium, and the pain- or dyspnea-related insomnia that undermines rehabilitation participation. CPAP/BiPAP is a skilled respiratory-device service, and a sleep-wake reversal is often the first sign of an acute change.
Module code | SNF-SLEEP |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Respiratory · Cognitive (delirium) · Pain · Behavioral · Skilled-Daily · Change of Condition |
MDS section(s) | O0110 (BiPAP/CPAP as a respiratory treatment) · D (sleep item in the mood screen) · I (sleep apnea; relevant diagnoses) |
Skilled category (Ch. 8) | Covered skilled procedures (CPAP/BiPAP device management) · observation & assessment of a sleep-wake change signaling delirium/decompensation · management & evaluation |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684 — 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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