← Document menuHome Care · DiraChart1. Purpose and clinical relevance
DiraChart Clinical Reference
Section NavigationPart 13 of 26PreviousNext 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.
Section NavigationPart 13 of 26PreviousNext