Gastrointestinal

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Trace DC97-10

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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9. Weak vs. strong documentation

Weak — does not survive

Why it fails

Strong — defensible

“Abdomen soft. Ostomy intact. Tolerating diet.”

No stoma viability/output, no peristomal detail, no skilled rationale.

The new-ostomy model note in §3: stoma color/viability, effluent, peristomal skin, appliance, teaching, and why skilled ostomy care was required.

“Dark stool noted.”

No characteristics, no vitals, no anticoagulation review, no action.

The re-bleed model note in §4: stool characteristics, vital/orthostatic trend, anticoagulant held, SBAR, labs/evaluation ordered.

“Ostomy care done.”

A task with no assessment or teaching — Section H unproven.

Document the viability/peristomal assessment, output, appliance change, and the teaching result.

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