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?
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
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