General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.8
Pain Management
Pain assessment (self-report scales and, for residents who cannot self-report, an observational scale such as PAINAD), the individualized pain plan, pharmacologic and non-pharmacologic management, opioid monitoring and bowel regimen, and reassessment of effect — the record surveyed under F697, cross-linked from every clinical reference.
Module code | SNF-PAIN |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Every clinical reference · Behavioral · Skilled-Daily · Post-Surgical and Pain-Management overlays |
MDS section(s) | J0100–J0850 (pain management; frequency; intensity; effect on function/sleep) · N (opioid) |
Survey F-tag(s) | F697 (pain management — recognize and manage pain consistent with professional standards) · F758 (opioid as unnecessary drug if unmonitored) |
How to use this module Fill every model note and smart phrase with the shift’s actual values and the resident’s current orders — these are structured examples to edit, never phrases to copy. The universal writing rules in Foundations (the necessity sentence, quantified outcomes, teach-back, closed-loop coordination, MDS-supportive documentation, and care-plan linkage) apply throughout and are not reprinted here. Disease-specific days route to the overlays. Verify each threshold and citation against the current source before use. |
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