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Manual page J-20DiraChart MDS item reference
J0800CSection Jv1.20.1Manual page J-20
Staff pain assessment: facial expressions
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Check all that apply
—
Not checked
Condition does not apply under the item instruction.
Manual page J-20Item-specific instructions
Coding Guidance
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Steps for Assessment
1. Review the medical record for documentation of
each indicator of pain listed in J0800 that occurred in the
last 5 days. If the record documents the presence of any of
the signs and symptoms listed, confirm your record review
with the direct care staff on all shifts who work most
closely with the resident during activities of daily living
(ADL).
2. Interview staff because the medical record may fail to
note all observable pain behaviors. For any indicators that
were not noted as present in medical record review,
interview direct care staff on all shifts who work with the
resident during ADL. Ask directly about the presence of
each indicator that was not noted as being present in the
record.
3. Observe resident during care activities. If you observe
additional indicators of pain in the last 5 days code the
corresponding items.
•
Observations for pain indicators may be more sensitive
if the resident is observed during ADL, or wound care.
Coding Instructions
Check all that apply in the last 5 days based on staff
observation of pain indicators.
•
If the medical record review and the interview with
direct care providers and observation on all shifts
provide no evidence of pain indicators, Check J0800Z, None of these signs observed or
documented, and proceed to the Shortness of Breath item (J1100).
•
Check J0800A, nonverbal sounds: included but not limited to if crying, whining,
gasping, moaning, or groaning were observed or reported in the last 5 days.
•
Check J0800B, vocal complaints of pain: included but not limited to if the
resident was observed to or reported to have made vocal complaints of pain (e.g. “that
hurts,” “ouch,” or “stop”) in the last 5 days.
•
Check J0800C, facial expressions: included but not limited to if grimaces,
winces, wrinkled forehead, furrowed brow, clenched teeth or jaw were observed or
reported in the last 5 days.
•
Check J0800D, protective body movements or postures: included but not
limited to if bracing, guarding, rubbing or massaging a body part/area, or clutching or
holding a body part during movement were observed or reported in the last 5 days.
DEFINITIONS
NON VERBAL SOUNDS
e.g., crying, whining,
gasping, moaning, groaning
or other audible indications
associated with pain.
VOCAL COMPLAINTS
OF PAIN
e.g., “That hurts,” “ouch,”
“stop,” etc.
FACIAL EXPRESSIONS
THAT MAY BE
INDICATORS OF PAIN
e.g., grimaces, winces,
wrinkled forehead, furrowed
brow, clenched teeth or jaw,
etc.
PROTECTIVE BODY
MOVEMENTS OR
POSTURES
e.g., bracing, guarding,
rubbing or massaging a body
part/area, clutching or
holding a body part during
movement, etc.
J0800: Indicators of Pain (cont.)
•
Check J0800Z, none of these signs observed or documented: if none of
these signs were observed or reported in the last 5 days.
Coding Tips
•
Behavior change, depressed mood, rejection of care and decreased activity participation
may be related to pain. These behaviors and symptoms are identified in other sections and
not reported here as pain screening items. However, the contribution of pain should be
considered when following up on those symptoms and behaviors.
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