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DiraChart Clinical Reference
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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 {###}. |
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.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. |
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.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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