Q:
I conducted the pain interview with a resident recently and they stated that they have ‘almost constant’ pain and rated it as ‘moderate’. I reviewed the chart and the resident has PRN analgesic available, but never requests it, and the Q shift Pain monitoring on the MAR indicates no pain during the look back period. How should I address this on the MDS?
A:
You should code the MDS according to the resident’s response to the interview questions. Then try to determine why there is an inconsistency to the interview vs. staff documentation.
-
-
- Did you conduct the interview during a time of day that the resident would be expected to have more pain, such as following a therapy session or after being up most of the day?
- Are staff actually asking the resident if they are experiencing pain when completing the monitoring documentation on the MAR, or documented ‘none’ because the resident had not verbalized any?
-
From Page J-7 of the RAI Manual – Planning for Care:
-
-
- Directly asking the resident about pain rather than relying on the resident to volunteer the information or relying on clinical observation significantly improves the detection of pain.
- Resident self-report is the most reliable means for assessing pain.
-
Take appropriate actions after determining the reason(s) for the inconsistency to ensure residents’ pain is accurately identified, documented and addressed on their care plan.
Angie Hamer RN, RAC-CT
Clinical Consultant
Click here to learn more about the rest of the Proactive team.