Pain Management

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Trace DC77-14

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Daily-note bank — change-of-condition / at-risk days

Scenario

Model daily note (edit to the shift)

New/uncontrolled pain

New right-hip pain 8/10 with movement (from a controlled baseline), limiting therapy — PQRST assessed, PRN given, provider notified, cause worked up, reassessed 30 min: 3/10; Section J/care plan updated.

Nonverbal pain via PAINAD

New grimacing/guarding/moaning with care, PAINAD 7 (from 1) — source assessed, PRN + non-pharm, reassessed 45 min: PAINAD 2, provider notified, scheduled analgesic requested; Section J updated.

Opioid oversedation

New sedation and RR 9 on the opioid — held, stimulated, O₂ applied, naloxone per order considered, provider notified; respiratory status and the regimen re-evaluated; event documented.

Linked disease-specific scenarios

Post-surgical and chronic-pain regimens route to the Post-Surgical and Pain-Management overlays; pain-driven behavior in dementia routes to the Behavioral reference; each clinical reference supplies its domain-specific pain (e.g., cardiac, wound, musculoskeletal).

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