General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.25
Communication
Skilled documentation when a communication deficit drives or complicates a Part A stay — aphasia and dysarthria after stroke, communication after tracheostomy or laryngectomy, cognitive-communication impairment, and the use of augmentative strategies. A deficit that blocks teaching, participation, and the ability to report pain or distress directly threatens the skilled plan and safety.
Module code | SNF-COMM |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Neurological · Cognitive · Ears/Hearing · Respiratory (trach) · Skilled-Daily · CVA overlay |
MDS section(s) | B0700 (makes self understood) · B0800 (ability to understand others) · C (cognition) · I (aphasia; relevant diagnoses) |
Skilled category (Ch. 8) | Observation & assessment of a communication change · teaching & training (communication strategies / AAC / caregiver) · management & evaluation (integrating the deficit into the skilled plan) |
Regulatory note | Coverage: Pub. 100-02 Ch. 8. Quality-of-care reference: F684 — 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. |
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