Neurological

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Trace DC95-12

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.

.NEURO_EXAM

Skilled neuro assessment: LOC {alert}, A&O×{#}, speech {clear/aphasia/dysarthria}, face {symmetric}, strength {RUE/LUE/RLE/LLE #/5 vs prior}, sensation {intact}, no new deficit / {change}. Swallowing {status} with {precautions}. Potential for change requires daily observation at SNF level. Supports Section GG/C; neuro goal {###}.

.NEURO_STROKE_ALERT

New {deficit} (negative last exam) — BE-FAST positive. Stroke/transfer pathway activated; provider + representative notified {time}; last-known-well {time}; vitals/glucose {values}; NPO. Reassess on return; MDS/CAA updated. Time-critical (anticoagulation {y/n}).

.NEURO_SEIZURE

Seizure: type {focal/generalized}, duration {##}, post-ictal {state}. Precautions in place; anticonvulsant {given}; SBAR to {provider}; representative notified; reassess. Supports Section I.

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