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DiraChart Clinical Reference
Section NavigationPart 10 of 15PreviousNext 9. Weak vs. strong documentation
Weak — does not survive | Why it fails | Strong — defensible |
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“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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