Gastrointestinal

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Trace DC34-13

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.

  • Abdominal and GI assessment with screening for an acute abdomen and GI bleeding.
  • Bowel-regimen management, particularly the prevention and treatment of opioid-induced constipation (coordinated with Pain).
  • Ostomy care and management — appliance changes, stoma and skin assessment, and output monitoring (with Lines / Drains / Devices).
  • Nausea management per order and coordination of diet and hydration (with Nutrition and Hydration).
  • Recognition of an acute abdomen or GI bleed with emergency activation, and coordination of evaluation.
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