MDS Alert

Published on Mon Jan 28, 2013 PDF

Find out what questions you should be asking the resident.

Is the resident in pain? Ask, "Have you had pain or hurting at any time in the last 5 days?" Depending on the response, here’s how you’ll report the patient’s pain:

"Coding Instructions for J0300, Pain Presence

Code for the presence or absence of pain regardless of pain management efforts during the 5-day lookback period.

Code 0, no: if the resident responds "no" to any pain in the 5-day look-back period.

Code 0, no: even if the reason for no pain is that the resident received pain management interventions. If coded 0, the pain interview is complete. Skip to Shortness of Breath item (J1100).

Code 1, yes: if the resident responds "yes" to pain at any time during the look-back period. If coded 1, proceed to items J0400, J0500, J0600 AND J0700.

Code 9, unable to answer: if the resident is unable to answer, does not respond, or gives a nonsensical response. If coded 9, skip to the Staff Assessment for Pain beginning with Indicators of Pain or Possible Pain item (J0800)." (Source: Printed verbatim from the RAI User’s Manual, page J-8.)

Remember the definition of pain when conducting this interview. Pain or discomfort can be present at rest or on movement; generalized or localized; acute or chronic; continuous or intermittent. Everyone is the owner of their pain which means that no one can discount another’s pain or discomfort. It is imperative that the interviewer accepts what a resident might say without comment or attempts to change the response. It is also important to educate staff to observe nonverbal indicators of pain: to document or report them so a staff assessment, when necessary, is accurate.