Pain

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Trace DC30-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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8. Interventions performed

Document the skilled interventions delivered this visit; each should connect to a finding and carry a reassessment in Section 10.

  • Analgesic administration or coordination per order, with reassessment at the appropriate interval and a documented effect.
  • Initiation or reinforcement of a bowel regimen for patients on opioids.
  • Nonpharmacologic measures per order — positioning, heat or cold, splinting, relaxation, or activity pacing.
  • Coordination of regimen titration or a change with the provider when pain is above goal or adverse effects appear.
  • Adverse-effect monitoring and mitigation — sedation and respiratory assessment on opioids, and management of nausea or constipation.
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