Hematologic

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Trace DC96-13

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)

Blood transfusion

PRBC unit administered after the two-person identity/consent check, interval vitals stable with no reaction signs, infused within the ordered time, post vitals/Hgb per order. Covered skilled transfusion with reaction surveillance; supports Section O. (Lines reference.)

Neutropenic precautions

On neutropenic precautions per a low ANC, afebrile with no infection signs, protective measures in place, counts monitored. Skilled infection surveillance and precaution management required (fever may be the only sign); supports Section O/I.

Thrombocytopenia precautions

Low platelets with bleeding precautions in place, no bruising/petechiae/mucosal bleeding, counts monitored, activity modified per order. Skilled bleeding surveillance required; supports Section I.

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