For residents who can self-report: PQRST (provocation, quality, region/radiation, severity 0–10, timing) and the effect on function and sleep.
For residents who cannot self-report (advanced dementia, nonverbal): an observational scale such as PAINAD (breathing, vocalization, facial expression, body language, consolability).
The plan, the pharmacologic/non-pharmacologic intervention delivered, and the reassessed effect with the time of reassessment; for opioids, sedation, respiratory status, and the bowel regimen.
MDS-supportive data
Pain frequency, intensity, and its effect on function/sleep are coded in MDS Section J (J0100–J0850); opioid days in Section N. The record must document the assessment and effect so Section J is supported (F641).
