DiraChart MDS item reference

J0100Section Jv1.20.1Manual page J-1

Pain Management

Item Rationale

Quick coding

Answer Codes

Use the item-specific response choices below when structured codes apply.

Response format: Instruction / group heading
0

No

if the medical record does not contain documentation that a scheduled pain medication was
received.

1

Yes

if the medical record contains documentation that a scheduled pain
medication was received.

Item-specific instructions

Coding Guidance

Review what the item asks, how to choose the response, and what should be verified before submission.

RAI Manual v1.20.1

Steps for Assessment

1. Review medical record to determine if a pain regimen
exists.
2. Review the medical record and interview staff and direct
caregivers to determine what, if any, pain management
interventions the resident received any time during the last
5 days. Include information from all disciplines.

Manual page J-1
RAI Manual v1.20.1

Coding Instructions

for J0100A-C
Determine all interventions for pain provided to the resident
any time in the last 5 days. Answer these items even if the
resident currently denies pain.
Coding Instructions for J0100A, Been on a
Scheduled Pain Medication Regimen

Code 0, no: if the medical record does not contain
documentation that a scheduled pain medication was
received.

Code 1, yes: if the medical record contains documentation that a scheduled pain
medication was received.
Coding Instructions for J0100B, Received PRN Pain Medication

Code 0, no: if the medical record does not contain documentation that a PRN
medication was received or offered.

Code 1, yes: if the medical record contains documentation that a PRN medication was
either received OR was offered but declined.
DEFINITIONS
SCHEDULED PAIN
MEDICATION REGIMEN
Pain medication order that
defines dose and specific
time interval for pain
medication administration.
For example, “once a day,”
“every 12 hours.”
PRN PAIN
MEDICATIONS
Pain medication order that
specifies dose and indicates
that pain medication may be
given on an as needed basis,
including a time interval,
such as “every 4 hours as
needed for pain” or “every 6
hours as needed for pain.”
NON-MEDICATION PAIN
INTERVENTION
Scheduled and implemented
nonpharmacological
interventions include, but are
not limited to, biofeedback,
application of heat/cold,
massage, physical therapy,
nerve block, stretching and
strengthening exercises,
chiropractic, electrical
stimulation, radiotherapy,
ultrasound and acupuncture.
Herbal or alternative
medicine products are not
included in this category.
J0100: Pain Management (cont.)
Coding Instructions for J0100C, Received Non-medication
Intervention for Pain

Code 0, no: if the medical record does not contain documentation that a non-
medication pain intervention was received.

Code 1, yes: if the medical record contains documentation that a non-medication pain
intervention was scheduled as part of the care plan and it is documented that the
intervention was actually received and assessed for efficacy.

Manual page J-1
RAI Manual v1.20.1

Coding Tips


Code only pain medication regimens without PRN pain medications in J0100A. Code
receipt of PRN pain medications in J0100B.

For J0100B code only residents with PRN pain medication regimens here. If the resident
has a scheduled pain medication J0100A should be coded.

Manual page J-1
MDS item matrix

Assessment Applicability

See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.

12 relationships4 groups
Official CMS source

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SourceCMS MDS 3.0 RAI Manual v1.20.1
Effective2025-10-01
Mapped locationManual page J-1
Reference details

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