Gastrointestinal

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Trace DC97-12

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.

.GI_OSTOMY

New-ostomy care ({type}, POD {#}): stoma {color/viable}, effluent {character/volume}, peristomal skin {status}, appliance {seal/changed}. Teaching {result}. Skilled stoma assessment and care required. Supports Section H; GI goal {###}.

.GI_BLEED

GI-bleed observation: stool/emesis {characteristics}, vitals {trend}, orthostasis {y/n}, pallor {y/n}, Hgb {##}. On anticoagulant {y/n} — {held per parameters}. Potential for re-bleed requires daily skilled monitoring. {SBAR/orders if change}. Supports Section I/N.

.GI_ABDOMEN

Abdominal assessment: {distension/tenderness/bowel sounds}, last BM {when/character}, nausea/vomiting {y/n}. {NPO/orders if concern}; provider notified {if}; monitoring for {obstruction/peritoneal signs}. Reassess {when}.

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