J0300: Pain Presence

J0300: Pain Presence

Steps for Assessment

1. Ask the resident: “Have you had pain or hurting at any time in the last 5 days?”

Coding Instructions for J0300, Pain Presence

Code for the presence or absence of pain regardless of pain management efforts in the last 5 days.

• Code 0, no: if the resident responds “no” to having any pain or hurting in the last 5 days. 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 having any pain or hurting in the last 5 days. If coded 1, proceed to the Pain Assessment Interview.

• 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.

Coding Tips

• Rates of self-reported pain are higher than observed rates. Although some observers have expressed concern that residents may not complain and may deny pain, the regular and objective use of self-report pain scales enhances residents’ willingness to report.

Examples

1. When asked about pain, Resident S responds, “No. I have been taking the pain medication regularly, so fortunately I have had no pain.”

Coding: J0300 would be coded 0, no.

Rationale: Resident S reports having no pain during the look-back period. Even though they received pain management interventions during the look-back period, the item is coded “No,” because there was no pain.

2. When asked about pain, Resident T responds, “No pain, but I have had a terrible burning sensation all down my leg.”

Coding: J0300 would be coded 1, yes.

Rationale: Although Resident T’s initial response is “no,” the comments indicate thatthey have experienced pain (burning sensation) during the look-back period.

3. When asked about pain, Resident G responds, “I was on a train in 1905.”

Coding: J0300 would be coded 9, unable to respond.

Rationale: Resident G has provided a nonsensical answer to the question. The assessor will complete the Staff Assessment for Pain.

DEFINITION

NONSENSICAL RESPONSE

Any unrelated, incomprehensible, or incoherent response that is not informative with respect to the item being coded.