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DiraChart Clinical Reference
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EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.
.PAIN_ASSESS Pain {##}/10 ({PQRST}) / PAINAD {##} for the nonverbal resident. Effect on {function/sleep}. Plan: {scheduled/PRN + non-pharm}. Supports Section J; comfort goal {###}. |
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.PAIN_INTERVENE Pain {##} → {intervention} per order → reassessed {min} later: {##}. Tolerance {status}. {Opioid monitoring: sedation, resp, bowel regimen}. Provider notified {if}. Effect and timing documented. |
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.PAIN_NONVERBAL Nonverbal resident: {grimacing/guarding/restlessness/vocalization} — PAINAD {##} (up from {##}). Source assessed; {analgesic + non-pharm}; reassessed {min}: PAINAD {##}. Provider notified; {scheduled analgesic requested}. Section J updated. |
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