9. Documentation smart phrases
Disease-specific phrases that supplement the parent module’s phrases. Each is a scaffold to complete with the visit’s actual values and orders — never a substitute for individualized documentation.
.DX_PAIN_GOAL Pain [score]/10; functional impact [described] vs ordered functional goal [goal]; goal [met/not met]; location/quality [see Pain assessment]; [action]. |
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.DX_PAIN_SAFETY Opioid-safety vitals: sedation [score on ordered scale], respiratory rate [value] (threshold <[value]); timing relative to dose [described]; dose [given/held]; [action]. |
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.DX_PAIN_NALOXONE Naloxone [present/absent], expiration [date/expired]; caregiver competence [confirmed/re-taught]; [action]. |
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.DX_PAIN_BOWEL Last bowel movement [interval] vs ordered interval [limit]; bowel regimen [effective/adjusted]; distension/pain/vomiting [none/described]; [action] (see GI). |
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.DX_PAIN_REGIMEN Opioid [agent/dose/schedule] adherence [described]; breakthrough use [frequency] vs ordered [limit]; escalation request [none/described]; adjuvants/non-pharm [described]. |
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.DX_PAIN_SCREEN Safety screen: concurrent alcohol/sedatives [none/described]; storage/disposal [safe/re-taught]; [action]. |
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.DX_PAIN_NOTIFY Provider notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [pain vs functional goal / safety vitals] next visit. |
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Cross-references. Pain (parent — full pain evaluation) · Gastrointestinal (opioid-induced constipation) · Respiratory (respiratory depression) · Cognitive/Mental Status (sedation, mood) · Medication Management.