MDS Alert

Published on Wed Nov 03, 2004 PDF

How would you code this resident's pain in Section J2?

Mrs. G, a resident with poor short- and long-term memory and moderately impaired cognitive function, asked the charge nurse for "a pill to make my aches and pains go away" once a day during the last seven days. The medication records shows that she received Tylenol every evening. The charge nurse states that Mrs. G usually rubs her left hip when she asks for a pill. However, when you ask her about pain, Mrs. G tells you that she is fine and never has pain.

Code a "2" (daily pain) for frequency and a "1" (mild pain), for pain intensity, according to the RAI manual. Rationale: Mrs. G appears to have forgotten that she has reported pain during the last seven days. Best clinical judgment calls for coding that reflects that Mrs. G has mild, daily pain.