General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.18
Lines, Drains & Devices
Skilled documentation for the Part A day for vascular access and drains — central and peripheral IV access (PICC, midline), IV-medication administration, and surgical/wound drains. A procedure-heavy module: the covered skilled procedures and the observation for line/drain complications that justify coverage. Tracheostomy routes to Respiratory; feeding tubes to Nutrition.
Module code | SNF-LINES |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Skilled-Daily · Skin · Musculoskeletal (post-op drains) · Respiratory (trach) · Nutrition (enteral) · Change of Condition |
MDS section(s) | O0110 (IV medications; IV access) · N (IV/anticoagulant medications) · I (infection; the treated condition) |
Skilled category (Ch. 8) | Covered skilled procedures (central/peripheral IV access care; IV-medication administration; drain management) · observation & assessment for line/drain complications · teaching · management & evaluation |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Infection-control reference: F880 (device-associated infection) — 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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