Section J. Health Conditions

Transcription

1 Sectin J Health Cnditins

2 Objectives 1 State the intent f Sectin J Health Cnditins. Identify health cnditins assessed in Sectin J that affect a resident s functinal status and quality f life. Describe hw t cnduct the Pain Assessment interview. Minimum Data Set (MDS) 3.0 Sectin J June

3 Objectives 2 Describe hw t cnduct the assessment fr ther health cnditins including histry f falls, shrtness f breath, and tbacc use. Cde Sectin J crrectly and accurately. Minimum Data Set (MDS) 3.0 Sectin J June

4 Intent f Sectin J Dcument health cnditins that impact a resident s functinal status and quality f life: Pain Dyspnea Tbacc use Prgnsis Prblem cnditins Falls Minimum Data Set (MDS) 3.0 Sectin J June

5 Pain Assessment Cnsists f an interview with resident. Cnduct a staff assessment nly if resident is unable t participate in the interview. Pain items assess: Presence f pain Frequency f pain Effect n functin Intensity Management Cntrl Minimum Data Set (MDS) 3.0 Sectin J June

6 Item J0100 Pain Management

7 J0100 Imprtance Pain can cause suffering and is assciated with: Inactivity Scial withdrawal Depressed md Functinal decline Pain can interfere with participatin in rehabilitatin. Effective pain management interventins can help t avid these adverse utcmes. Minimum Data Set (MDS) 3.0 Sectin J June

8 J0100 Cnduct the Assessment Determine what, if any, pain management interventins the resident received during the lk-back perid. Review the medical recrd. Interview staff and direct caregivers. Minimum Data Set (MDS) 3.0 Sectin J June

9 J0100 Assessment Guidelines The lk-back perid is 5 days. Include infrmatin frm all disciplines. Determine all interventins prvided t the resident. Answer these items even if resident denies pain. Minimum Data Set (MDS) 3.0 Sectin J June

10 J0100A Scheduled Pain Medicatin Regimen Cding Instructins Cde 0. N if medical recrd des nt cntain dcumentatin that a scheduled pain medicatin was received. Cde 1. Yes if medical recrd cntains dcumentatin that a scheduled pain medicatin was received. Minimum Data Set (MDS) 3.0 Sectin J June

11 J0100B Received PRN Pain Medicatins Cding Instructins Cde 0. N if recrd des nt cntain dcumentatin that a PRN medicatin was received r ffered. Cde 1. Yes if recrd cntains dcumentatin that a PRN medicatin was either received OR ffered but was declined. Minimum Data Set (MDS) 3.0 Sectin J June

12 J0100C Received Nn-Medicatin Interventin Cding Instructins Cde 0. N if medical recrd des nt cntain dcumentatin that a nn-medicatin pain interventin was received. Cde 1. Yes if medical recrd cntains dcumentatin that: Nn-medicatin pain interventin scheduled as part f the care plan. Interventin actually received and assessed fr efficacy. Minimum Data Set (MDS) 3.0 Sectin J June

13 J0100 Scenari The resident s medical recrd dcuments that she received the fllwing pain management in the past 5 days: Hydrcdne/ acetaminphen 5/ tab PO every 6 hurs. Discntinued n day 1 f lk-back perid. Acetaminphen 500mg PO every 4 hurs. Started n day 2 f lk-back perid. Cld pack t left shulder applied by PT BID. PT ntes that resident reprts significant pain imprvement after cld pack applied. Minimum Data Set (MDS) 3.0 Sectin J June

14 J0100 Scenari Cding 1 Cde J0100A as 1. Yes. The medical recrd indicated that the resident received a scheduled pain medicatin during the 5-day lk-back perid. Cde J0100B as 0. N. N dcumentatin was fund in the medical recrd that the resident received r was ffered and declined any PRN medicatins during the 5-day lk-back perid. Minimum Data Set (MDS) 3.0 Sectin J June

15 J0100 Scenari Cding 2 Cde J0100C as 1. Yes. The medical recrd indicates that the resident received scheduled nn-medicatin pain interventin (cld pack t the left shulder) during the 5-day lk-back perid. Minimum Data Set (MDS) 3.0 Sectin J June

16 J0100 Pain Management Practice The resident s medical recrd includes the fllwing pain management dcumentatin: MS-Cntin (mrphine sulfate cntrlled-release) 15 mg PO Q 12 hurs. Resident refused every dse f medicatin during the 5-day lk-back perid. N ther pain management interventins were dcumented. Minimum Data Set (MDS) 3.0 Sectin J June

17 Hw shuld J0100A be cded? A. Cde 0. N. B. Cde 1. Yes. Minimum Data Set (MDS) 3.0 Sectin J June

18 J0100A Cding The crrect cding is 0. N. The medical recrd dcumented that the resident did nt receive scheduled pain medicatin during the 5-day lk-back perid. Residents may refuse scheduled medicatins. Medicatins are nt cnsidered received if the resident refuses the dse. Minimum Data Set (MDS) 3.0 Sectin J June

19 Hw shuld J0100B be cded? A. Cde 0. N. B. Cde 1. Yes. Minimum Data Set (MDS) 3.0 Sectin J June

20 J0100B Cding The crrect cding is 0. N. The medical recrd cntained n dcumentatin that the resident received r was ffered and declined any PRN medicatins during the 5-day lk-back perid. Minimum Data Set (MDS) 3.0 Sectin J June

21 Hw shuld J0100C be cded? A. Cde 0. N. B. Cde 1. Yes. Minimum Data Set (MDS) 3.0 Sectin J June

22 J0100C Cding The crrect cding is 0. N. The medical recrd cntains n dcumentatin that the resident received nn-medicatin pain interventin during the 5-day lk-back perid. Minimum Data Set (MDS) 3.0 Sectin J June

23 Item J0200 Shuld Pain Assessment Interview Be Cnducted?

24 J0200 Imprtance Mst residents capable f cmmunicating can answer questins abut hw they feel. Obtaining infrmatin abut pain directly frm the resident is mre reliable and accurate than bservatin alne fr identifying pain. Use staff bservatins fr pain behavir nly if a resident cannt cmmunicate. Verbally With gestures In writing Minimum Data Set (MDS) 3.0 Sectin J June

25 J0200 Cnduct the Assessment Determine whether resident is understd at least smetimes. Review A1100 t determine whether resident needs r wants an interpreter. Make every effrt t have an interpreter present if needed r requested. Minimum Data Set (MDS) 3.0 Sectin J June

26 J0200 Assessment Guidelines Skip t J1100 if the resident is cmatse. B0100 is cded 1. Yes. Minimum Data Set (MDS) 3.0 Sectin J June

27 J0200 Cding Instructins Cde 0. N if resident is rarely/ never understd r an interpreter is required but nt available. Cde 1. Yes if resident is at least smetimes understd and an interpreter is present r nt required. Minimum Data Set (MDS) 3.0 Sectin J June

28 Item J0300- J0600 Pain Assessment Interview

29 Imprtance f Pain Assessment 1 Effects f unrelieved pain impact the individual. Functinal decline Cmplicatins f immbility Skin breakdwn Infectins Pain significantly adversely affects quality f life. Depressed md Diminished self-cnfidence and self-esteem Increase in behavir prblems, particularly fr cgnitively-impaired residents Minimum Data Set (MDS) 3.0 Sectin J June

30 Imprtance f Pain Assessment 2 Sme lder adults limit their activities in rder t avid having pain. Their reprt f lwer pain frequency may reflect their avidance f activity mre than it reflects adequate pain management. Minimum Data Set (MDS) 3.0 Sectin J June

31 Pain Assessment Interview Interview any resident nt screened ut by J0200. The interview cnsists f 4 questins. Begins with the primary questin. J0300 Pain Presence Includes 3 fllw-up items. J0400 Pain Frequency J0500 Pain Effect n Functin J0600 Pain Intensity Minimum Data Set (MDS) 3.0 Sectin J June

32 Pain Assessment Interview Guidelines 1 The lk-back perid fr all pain interview items is 5 days. Cnduct the interview clse t the end f the 5-day lk-back perid. Skip t the Staff Assessment if the resident is unable t answer J0300 Pain Presence. Stp the interview and skip t the Staff Assessment if the resident is unable t answer J0400 Pain Frequency. Minimum Data Set (MDS) 3.0 Sectin J June

33 Pain Assessment Interview Guidelines 2 Ask each questin in rder. Use ther terms fr pain r fllw-up discussin if the resident seems unsure r hesitant. Cde 9 if the resident refuses t answer a questin and mve n t the next questin. If the resident is unsure abut whether pain ccurred during the lk-back perid: Prmpt resident t think abut the mst recent episde. Try t determine whether it ccurred during the lkback perid. Minimum Data Set (MDS) 3.0 Sectin J June

34 Cnduct the Interview Establish a cnducive envirnment. Use an interpreter if needed. Make sure the resident can hear yu. Explain the reasn fr the interview. Explain the respnse chices. Shw respnses in large fnt as apprpriate. Allw resident t write respnses if needed. Minimum Data Set (MDS) 3.0 Sectin J June

35 Item J0300 Pain Presence

36 J0300 Pain Presence Cnduct the Assessment/ Guidelines Ask the questin as written. Cde fr the presence r absence f pain regardless f pain management effrts. Rates f self-reprted pain are higher than bserved rates. Minimum Data Set (MDS) 3.0 Sectin J June

37 J0300 Cding Instructins 1 Cde 0. N. Resident respnds n t presence f pain. Even if resident received pain management interventins. Interview is cmplete. Skip t J1100 Shrtness f Breath. Cde 1. Yes. Resident respnds yes t presence f pain during the lk-back perid. Cntinue with the pain assessment interview. Minimum Data Set (MDS) 3.0 Sectin J June

38 J0300 Cding Instructins 2 Cde 9. Unable t answer. Is unable t answer. Des nt respnd. Gives a nnsensical respnse. Skip t the Staff Assessment fr Pain (J0800). Minimum Data Set (MDS) 3.0 Sectin J June

39 J0300 Scenari When asked abut pain, Mrs. S. respnds, N. I have been taking the pain medicatin regularly, s frtunately I have had n pain. Minimum Data Set (MDS) 3.0 Sectin J June

40 J0300 Scenari Cding Cde J0300 as 0. N. Mrs. S. reprts having n pain during the lk-back perid. Even thugh she received pain management interventins during the lk-back perid, the item is cded N because there was n pain. Skip t J1100. Shrtness f Breath. Minimum Data Set (MDS) 3.0 Sectin J June

41 J0300 Practice #1 When asked abut pain, Mr. T. respnds, N pain, but I have had a terrible burning sensatin all dwn my leg. Minimum Data Set (MDS) 3.0 Sectin J June

42 Hw shuld J0300 be cded? A. Cde 0. N. B. Cde 1. Yes. C. Cde 9. Unable t answer. Minimum Data Set (MDS) 3.0 Sectin J June

43 J0300 Practice #1 Cding The crrect cding is 1. Yes. Althugh Mr. T. s initial respnse is n, the cmments indicate that he has experienced pain (burning sensatin) during the lk-back perid. Minimum Data Set (MDS) 3.0 Sectin J June

44 Item J0400 Pain Frequency

45 J0400 Pain Frequency Cnduct the Assessment Ask the questin exactly as written. May use cue cards t present respnse ptins. Minimum Data Set (MDS) 3.0 Sectin J June

46 J0400 Pain Frequency Assessment Guidelines D nt ffer definitins f respnse ptins. Resident s respnse shuld be based n the resident s interpretatin f the frequency ptins. Use eching t help clarify the preferred ptin if the resident des nt respnd accrding t the respnse scale. Stp the interview and skip t J0800 t cmplete the Staff Assessment fr Pain if the resident is unable t respnd t this item. Minimum Data Set (MDS) 3.0 Sectin J June

47 J0400 Cding Instructins Cde the resident s respnse. If the resident has difficulty chsing between tw respnses: Use eching t help resident clarify the respnse. Cde the mre frequent f the tw respnses. Minimum Data Set (MDS) 3.0 Sectin J June

48 J0400 Scenari When asked abut pain, Ms. M. respnds, I wuld say rarely. Since I started using the patch, I dn t have much pain at all, but fur days ag the pain came back. I think they were a bit verdue in putting n the new patch, s I had sme pain fr a little while that day. Minimum Data Set (MDS) 3.0 Sectin J June

49 J0400 Scenari Cding Cde J0400 as 4. Rarely. Ms. M. selected the rarely respnse ptin. Minimum Data Set (MDS) 3.0 Sectin J June

50 J0400 Practice #1 When asked abut pain, Miss K. respnds: I can t remember. I think I had a headache a few times in the past cuple f days, but they gave me Tylenl and the headaches went away. Interviewer clarifies by eching what Miss K. said: Yu ve had a headache a few times in the past cuple f days and the headaches went away when yu were given Tylenl. If yu had t chse frm the answers, wuld yu say yu had pain ccasinally r rarely? Miss K. replies Occasinally. Minimum Data Set (MDS) 3.0 Sectin J June

51 Hw shuld J0400 be cded? A. Cde 1. Almst cnstantly B. Cde 2. Frequently C. Cde 3. Occasinally D. Cde 4. Rarely E. Cde 9. Unable t answer Minimum Data Set (MDS) 3.0 Sectin J June

52 J0400 Practice #1 Cding The crrect cding is 3. Occasinally. After the interviewer clarified the resident s chice using eching, the resident selected a respnse ptin. Minimum Data Set (MDS) 3.0 Sectin J June

53 J0400 Practice #2 When asked abut pain, Mr. J. respnds: I dn t knw if it is frequent r ccasinal. My knee starts thrbbing every time they mve me frm the bed r the wheelchair. The interviewer says: Yur knee thrbs every time they mve yu. If yu had t chse an answer, wuld yu say that yu have pain frequently r ccasinally? Mr. J. is still unable t chse between frequently and ccasinally. Minimum Data Set (MDS) 3.0 Sectin J June

54 Hw shuld J0400 be cded? A. Cde 1. Almst cnstantly B. Cde 2. Frequently C. Cde 3. Occasinally D. Cde 4. Rarely E. Cde 9. Unable t answer Minimum Data Set (MDS) 3.0 Sectin J June

55 J0400 Practice #2 Cding The crrect cding is 2. Frequently. The interviewer apprpriately eched Mr. J. s cmment and prvided related respnse ptins t help him clarify which respnse he preferred. Mr. J. remained unable t decide between frequently and ccasinally. The interviewer, therefre, cded fr the higher frequency f pain. Minimum Data Set (MDS) 3.0 Sectin J June

56 Item J0500 Pain Effect n Functin

57 J0500 Pain Effect n Functin Cnduct the Assessment Ask each questin as written. Minimum Data Set (MDS) 3.0 Sectin J June

58 J0500 Pain Effect n Functin Assessment Guidelines Repeat the respnse and try t narrw the fcus f the respnse if the resident s respnse des nt clearly indicate yes r n. J0500A Over the past 5 days, has pain made it hard fr yu t sleep at night? Resident respnds, I always have truble sleeping. Try t help clarify the respnse, Yu always have truble sleeping. Is it yur pain that makes it hard fr yu t sleep? Minimum Data Set (MDS) 3.0 Sectin J June

59 J0500 Cding Instructins Cde the resident s respnse t each questin. Minimum Data Set (MDS) 3.0 Sectin J June

60 J0500A Scenari Mrs. D. respnds, I had a little back pain frm being in the wheelchair all day, but it felt s much better when I went t bed. I slept like a baby. Minimum Data Set (MDS) 3.0 Sectin J June

61 J0500A Scenari Cding Cde J0500A as 0. N. Mrs. D. reprts n sleep prblems related t pain. Minimum Data Set (MDS) 3.0 Sectin J June

62 J0500A Practice #1 Miss G. respnds, Yes, the back pain makes it hard t sleep. I have t ask fr extra pain medicine, and I still wake up several times during the night because my back hurts s much. Minimum Data Set (MDS) 3.0 Sectin J June

63 Hw shuld J0500A be cded? A. Cde 0. N. B. Cde 1. Yes. C. Cde 9. Unable t answer. Minimum Data Set (MDS) 3.0 Sectin J June

64 J0500A Practice #1 Cding The crrect cding is 1. Yes. The resident reprts pain-related sleep prblems. Minimum Data Set (MDS) 3.0 Sectin J June

65 J0500A Practice #2 Mr. E. respnds, I can t sleep at all in this place. The interviewer clarifies by saying, Yu can t sleep here. Wuld yu say that was because pain made it hard fr yu t sleep at night? Mr. E. respnds, N. It has nthing t d with me. I have n pain. It is because everyne is making s much nise. Minimum Data Set (MDS) 3.0 Sectin J June

66 Hw shuld J0500A be cded? A. Cde 0. N. B. Cde 1. Yes. C. Cde 9. Unable t answer. Minimum Data Set (MDS) 3.0 Sectin J June

67 J0500A Practice #2 Cding The crrect cding is 0. N. Mr. E. reprts that his sleep prblems are nt related t pain. Minimum Data Set (MDS) 3.0 Sectin J June

68 J0500B Scenari Mrs. N. respnds, Yes, I haven t been able t play the pian, because my shulder hurts. Minimum Data Set (MDS) 3.0 Sectin J June

69 J0500B Scenari Cding Cde J0500B as 1. Yes. Mrs. N. reprts limiting her activities because f pain. Minimum Data Set (MDS) 3.0 Sectin J June

70 J0500B Practice #1 Ms. L. respnds, N, I had sme pain n Wednesday, but I didn t want t miss the shpping trip, s I went. Minimum Data Set (MDS) 3.0 Sectin J June

71 Hw shuld J0500B be cded? A. Cde 0. N. B. Cde 1. Yes. C. Cde 9. Unable t answer. Minimum Data Set (MDS) 3.0 Sectin J June

72 J0500B Practice #1 Cding The crrect cding is 0. N. Althugh Ms. L. reprts pain, she did nt limit her activity because f it. Minimum Data Set (MDS) 3.0 Sectin J June

73 J0500B Practice #2 Mrs. S. respnds, I dn t knw. I have nt tried t knit since my finger swelled up yesterday, because I am afraid it might hurt even mre than it des nw. Minimum Data Set (MDS) 3.0 Sectin J June

74 Hw shuld J0500B be cded? A. Cde 0. N. B. Cde 1. Yes. C. Cde 9. Unable t answer. Minimum Data Set (MDS) 3.0 Sectin J June

75 J0500B Practice #2 Cding The crrect cding is 1. Yes. Mrs. S. avided a usual activity because f fear that her pain wuld increase. Minimum Data Set (MDS) 3.0 Sectin J June

76 Item J0600 Pain Intensity

77 J0600 Pain Intensity Numeric Rating Scale (scale f 00 t 10) Verbal Descriptr Scale Cmplete nly ne f these items, nt bth. Minimum Data Set (MDS) 3.0 Sectin J June

78 J0600 Cnduct the Assessment Read the questin and respnse ptins slwly. Ask the resident t rate his r her wrst pain. Please rate yur wrst pain ver the last 5 days with zer being n pain, and ten as the wrst pain yu can imagine. Please rate the intensity f yur wrst pain ver the last 5 days. Use cue cards t shw respnse ptins if needed. Minimum Data Set (MDS) 3.0 Sectin J June

79 J0600 Assessment Guidelines The lk-back perid is 5 days. Try t use the same scale used n prir assessments. If a resident is unable t answer using ne scale, try the ther scale. The resident may answer three ways: Verbally In writing Bth Minimum Data Set (MDS) 3.0 Sectin J June

80 J0600A Numeric Rating Scale Cding Instructins Cde as a tw-digit value. Use a leading zer fr values less than 10. Enter 99 if unable t answer r des nt answer. Leave the respnse fr J0600B blank. Minimum Data Set (MDS) 3.0 Sectin J June

81 J0600B Verbal Descriptr Scale Cding Instructins Cde as a ne-digit value. Enter 9 if unable t answer r des nt answer. Leave the respnse fr J0600A blank. Minimum Data Set (MDS) 3.0 Sectin J June

82 J0600 Scenari #1 The nurse asks Ms. T. t rate her pain n a scale f 0 t 10. Ms. T. states that she is nt sure, because she has shulder pain and knee pain, and smetimes it is really bad, and smetimes it is OK. The nurse reminds Ms. T. t think abut all the pain she had during the last 5 days and select the number that describes her wrst pain. She reprts that her pain is a 6. Minimum Data Set (MDS) 3.0 Sectin J June

83 J0600 Scenari #1 Cding Cde J0600A as 06. The resident said her pain was 6 n the 0 t 10 scale. Minimum Data Set (MDS) 3.0 Sectin J June

84 J0600 Scenari #2 The nurse asks Mr. R. t rate his pain using the verbal descriptr scale. He lks at the respnse ptins presented using a cue card and says his pain is severe smetimes, but mst f the time it is mild. Minimum Data Set (MDS) 3.0 Sectin J June

85 J0600 Scenari #2 Cding Cde J0600B as 3. Severe. The resident said his wrst pain was Severe. Minimum Data Set (MDS) 3.0 Sectin J June

86 Sectin J Pain Assessment Interview Activity

87 Activity Instructins Turn t Sectin J items J J0600 in the MDS 3.0 instrument. Watch the Pain Interview vide. Cde the interview in the MDS 3.0. Minimum Data Set (MDS) 3.0 Sectin J June

88 Pain Assessment Interview Vide The Vide n Interviewing Vulnerable Elders (VIVE) was funded by the Picker Institute and prduced by the UCLA/JH Brun Center. DVD cpies can be rdered frm the Pineer Netwrk. Minimum Data Set (MDS) 3.0 Sectin J June

89 Pain Assessment Interview Cding J Yes J Almst cnstantly J0500A (sleep) 1. Yes J0500B (activities) 1. Yes J0600A Numeric Rating Scale cde 08 Minimum Data Set (MDS) 3.0 Sectin J June

90 Item J0700 Shuld the Staff Assessment fr Pain Be Cnducted

91 J0700 Imprtance Resident interview fr pain is preferred because it imprves the detectin f pain. A small percentage f residents is unable r unwilling t cmplete the pain interview. Persns unable t cmplete the pain interview may still have pain. Minimum Data Set (MDS) 3.0 Sectin J June

92 J0700 Cnduct the Assessment Review the resident s respnses t J J0400. Determine if the pain assessment interview was cmpleted. J0300 Presence f Pain cded 0. N. OR J0300 Presence f Pain cded 1. Yes. J0400 Pain Frequency is answered. Minimum Data Set (MDS) 3.0 Sectin J June

93 J0700 Cding Instructins Cde 0. N. Resident cmpleted the Pain Assessment Interview. Skip t J1100 Shrtness f Breath (dyspnea). Cde 1. Yes. Resident unable t cmplete the Pain Assessment Interview. Cntinue t J0800 Indicatrs f Pain r Pssible Pain. Minimum Data Set (MDS) 3.0 Sectin J June

94 Items J0800 & J0850 Staff Assessment fr Pain

95 J0800/ J0850 Imprtance 1 Residents wh cannt verbally cmmunicate abut their pain are at particularly high risk fr underdetectin and undertreatment f pain. Severe cgnitive impairment may affect ability f residents t cmmunicate verbally. Limits availability f self-reprted infrmatin abut pain. Fewer cmplaints may nt mean less pain. Individuals unable t cmmunicate verbally may be mre likely t use alternative methds f expressin t cmmunicate pain. Minimum Data Set (MDS) 3.0 Sectin J June

96 J0800/ J0850 Imprtance 2 Sme verbal cmplaints f pain may be made and shuld be taken seriusly. Unrelieved pain adversely affects functin and mbility, cntributing t: Dependence Cntractures Skin breakdwn Weight lss Pain significantly adversely affects quality f life and is tightly linked t depressed md, diminished selfcnfidence and self-esteem, as well as t an increase in behavir prblems. Minimum Data Set (MDS) 3.0 Sectin J June

97 Indicatrs f Pain 1 Nn-Verbal Sunds include but nt limited t: Crying Maning Whining Graning Gasping Other audible indicatins Vcal Cmplaints f Pain include but nt limited t: That hurts. Ouch. Stp. Minimum Data Set (MDS) 3.0 Sectin J June

98 Indicatrs f Pain 2 Facial Expressins include but nt limited t: Grimaces Furrwed brw Winces Clenched teeth r jaw Wrinkled frehead Prtective Bdy Mvements r Gestures include but nt limited t: Bracing Guarding Rubbing/ massaging a bdy part Clutching/ hlding a bdy part during mvement Minimum Data Set (MDS) 3.0 Sectin J June

99 J0800 Cnduct the Assessment Review the medical recrd. Lk fr dcumentatin f indicatrs f pain. Cnfirm presence f indicatrs f pain with direct care staff n all shifts wh wrk with resident during ADLs. Interview staff. Questin staff wh bserve r assist the resident. Ask abut presence f each indicatr nt in the recrd. Observe the resident. Minimum Data Set (MDS) 3.0 Sectin J June

100 J0800 Assessment Guidelines The lk-back perid is 5 days. Sme symptms may be related t pain: Behavir change Depressed md Rejectin f care Decreased participatin in activities D nt reprt these symptms here as pain screening items. Minimum Data Set (MDS) 3.0 Sectin J June

101 J0800 Cding Instructins Check all indicatrs f pain that apply. Based n staff bservatin f indicatrs f pain. Check Z if n indicatrs f pain are bserved. Minimum Data Set (MDS) 3.0 Sectin J June

102 J0800 Scenari Mr. P. has advanced dementia and is unable t verbally cmmunicate. A nte in his medical recrd dcuments that he has been awake during the last night crying and rubbing his elbw. When yu g t his rm t interview the certified nurse aide (CNA) caring fr him, yu bserve Mr. P. grimacing and clenching his teeth. The CNA reprts that he has been maning and said uch when she tried t mve his arm. Minimum Data Set (MDS) 3.0 Sectin J June

103 J0800 Scenari Cding Mr. P. has demnstrated: Nn-verbal sunds (crying and maning) Vcal cmplaints f pain ( uch ) Facial expressin f pain (grimacing and clenched teeth) Prtective bdy mvements (rubbing his elbw) Minimum Data Set (MDS) 3.0 Sectin J June

104 J0850 Frequency f Pain Indicatrs Assessment f pain frequency prvides: Basis fr evaluating treatment need and respnse t treatment Infrmatin t aide in identifying ptimum timing f treatment Interview staff and direct caregivers. Determine number f days the resident either cmplained f pain r shwed evidence f pain during the lk-back perid. The lk-back perid is 5 days. Minimum Data Set (MDS) 3.0 Sectin J June

105 J0850 Cding Instructins Cde 1 if indicatrs bserved 1-2 days. Cde 2 if indicatrs bserved 3-4 days. Cde 3 if indicatrs bserved daily. D nt cde the number f times that indicatrs f pain were bserved r dcumented. Minimum Data Set (MDS) 3.0 Sectin J June

106 J0850 Scenari Mr. M. is an 80-year ld male with advanced dementia. Mr. M. was nted t be grimacing and verbalizing uch ver the past 2 days when his right shulder was mved during the 5-day lk-back perid. Minimum Data Set (MDS) 3.0 Sectin J June

107 J0850 Scenari Cding Cde J0850 as 1. Indicatrs f pain r pssible pain bserved 1 2 days. He has demnstrated vcal cmplaints f pain ( uch ) and facial expressin f pain (grimacing) n 2 f the last 5 days. Minimum Data Set (MDS) 3.0 Sectin J June

108 Sectin J Summary

109 Pain Assessment Cmplete a pain assessment interview if at all pssible. When determining the assessment fr pain intensity, use either the Verbal Descriptr Scale r the Numeric Rating Scale, nt bth. Cmplete the staff assessment fr pain nly if an interview cannt be cmpleted. Cmplete a pain assessment even if the resident denies pain. Minimum Data Set (MDS) 3.0 Sectin J June