General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.16
Gastrointestinal System
Skilled GI documentation for the Part A day — recovery from a GI bleed, post-abdominal surgery, new ostomy care, bowel-obstruction recovery, and severe/infectious diarrhea (including C. difficile). Proves the skilled GI observation, ostomy/procedure care, and management that an unstable GI course requires daily. Enteral feeding routes to Nutrition.
Module code | SNF-GI |
|---|---|
Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Nutrition (enteral) · Continence (bowel) · Skilled-Daily · Anticoagulation overlay · Change of Condition |
MDS section(s) | H (bowel continence; ostomy) · K (nutrition; feeding tube) · O (IV medication; isolation) · I (GI diagnoses) |
Skilled category (Ch. 8) | Observation & assessment of an unstable GI status · covered skilled procedures (new-ostomy care; IV medication) · teaching (ostomy) · management & evaluation |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684; infection control for C. difficile (F880) — 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. |
|---|