Long-Term Care

Coding pain under Section J on the MDS 3.0

MDS 3.0 Insider, January 11, 2010

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Coding for pain under Section J: Health Conditions of the MDS 3.0 has increased markedly in length, compared with the MDS 2.0. The instructions for the MDS 3.0 provide information for each section describing the item rationale related to quality of life and care plan issues specific to the section. Definitions pertaining to the item are framed in text boxes and interspersed throughout each section of the instructions that will be in the Resident Assessment Instrument User's Manual.
 
Coding pain under Section J on the MDS 3.0
J0100: Pain Management
  • The assessment period for pain is five days (it is seven days on the MDS 2.0).
Coding Instructions for J0100A–C
Answer these items even if the resident denies pain:
  • Coding Instructions for J0100A, Been on a Scheduled Pain Medication Regimen
    • (Code only pain medication regimens without PRN pain medications in J0100A.)
    • Code 0, no, if there is no documentation that a scheduled pain medication was given.
    • Code 1, yes, if the record indicates that a scheduled analgesic was given.
  • Coding Instructions for J0100B, Received PRN Pain Medication
    • (Code this section only if the resident received PRN pain medications, or refused when they were offered.)
    • Code 0, no, if there is no documentation that a PRN medication was offered or received.
    • Code 1, yes, if there is documentation that a PRN medication was either received or was offered but refused.
  • Coding Instructions for J0100C, Received Non-Medication Intervention for Pain
    • Code 0, no, if there is no documentation that a non-medication pain intervention was received.
    • Code 1, yes, if there is documentation that a non-medication pain intervention was scheduled as part of the care plan, and documentation reflects that the intervention was actually received and evaluated for efficacy.
 More information on coding Section J can be found in Barbara Acello's newest book, Clinical Pain Management: An Essential Handbook for Long-Term Care Nurses.
 



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