General Section
SKILLED DOCUMENTATION GUIDELINES — EXPANDED
DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Disease Overlay · 3.5
Pain Management
Pain management overlay, with an emphasis on opioid safety. Supplements the Pain assessment with the functional pain goal, the sedation and respiratory-rate monitoring that opioid safety requires, naloxone readiness, opioid-induced-constipation management, and safe-use teaching. It does not replace the Pain assessment — the full pain evaluation lives there; this overlay adds the disease- and therapy-specific parameters, monitoring, and escalation. The focus is safe, effective pain control and the prevention of opioid-related harm.
Overlay code | DX-PAIN |
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Version | 1.0 · Population: Adult · Authoring level: DiraChart (read-only baseline; agencies may append) |
Supplements | Pain (parent core-domain assessment) · Gastrointestinal (opioid-induced constipation) · Respiratory (respiratory depression) · Cognitive / Mental Status (sedation) · Medication Management |
How to use this overlay Apply this overlay whenever a pain regimen — especially one including opioids — is on the plan of care, alongside the Pain assessment. Section 2 states the functional pain goal and the opioid-safety notify thresholds (sedation and respiratory rate, naloxone, bowel interval) in self-contained terms so a nurse covering the patient can act on them without prior knowledge of the patient — always confirmed against the current orders. Every scenario states the actual finding and its objective reference (the ordered regimen, a measured respiratory rate and sedation score, the functional goal), never “at baseline.” Pin the clinical detail to the current CDC opioid-prescribing guidance. Each phrase and scenario is a scaffold to complete with the visit’s actual values — not a phrase to copy. |
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