MDS Alert
Coding Quizzer ~ Don't Let Cognitive Impairment Derail Pain Assessment
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How would you code this resident's frequency and intensity of pain? Answers: J2a=1; J2b=2
Coding Scenario: Mrs. S is severely cognitively impaired. She is unable to make decisions and requires extensive assistance for daily ADL care. The CNA responsible for her care and daily ambulation reports to the charge nurse that she has noticed Mrs. C to have "pain in her back" when the CNA attempts to position her in bed and transfer her to a chair. The nurse observes Mrs. S's physical, facial and verbal expressions during care and determines that the resident is experiencing moderate pain.
The physician is notified and orders Tylenol q 6 hours. The resident appears relieved later in the day. The resident is observed by nursing staff and they determine that she is no longer experiencing a moderate level of pain. The physician determines that the resident should continue on the medication for several days.
See the answer below. (Source: RAI Manual, chapter 3.)
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