Sharpening Pain Management Charting

Pain is a significant issue for many nursing home residents that can negatively impact quality of life when not appropriately managed. Unrelieved pain can lead to a decline in the resident’s function, cognitive, mood, behavior, and psychosocial status. An effective pain management program focuses on improving quality of life by maintaining an optimal level of function through relief and control of pain. This is best accomplished by screening for and recognizing pain in individuals, completing a comprehensive assessment of the pain, and developing individualized care plan interventions based on the assessment. Determine how well your pain management charting measures up as part of §483.25 Quality of Care compliance.

Screening for pain: A pain screening should be completed in all residents to identify if pain is present:

• • • Initially on admission
    • With any condition changes
    • At least quarterly

For any residents that are positive for the presence of pain, a further in-depth comprehensive assessment should be completed. The MDS interview for pain is an excellent screening tool designed to identify the presence of pain, frequency and intensity of pain, and the effect of the pain, but it is not sufficient as a comprehensive assessment of the pain.

Pain Assessment: The comprehensive pain assessment is essential to the identification of appropriate treatment and pain management interventions. The elements of the comprehensive pain assessment should include the following:

• • • Pain history including the etiology, related diagnoses, causes
    • Pain onset
    • Precipitating event – What happened when the pain started?
    • Associated symptoms – Nausea, vomiting, fever
    • Location of pain including a visual and tactile assessment of the area
    • Description of the pain (what does it feel like)
    • Frequency, intensity, and duration of pain
    • Variability – is the pain constant or intermittent? Does it vary in intensity?
    • Aggravating factors (what makes the pain worse) and relieving factors (what makes the pain better)
    • Effect of any current and/or previous treatment interventions including pharmacological and non-medication interventions
    • Impact of pain on function
    • Level of pain that is desirable or tolerable for the resident.

Individualized Pain Care Plans: Based on the comprehensive assessment each resident should have an individualized Interdisciplinary care plan aimed at improving quality of life through adequate pain control and management. Pain care plans should include the following elements:

• • • Problem/Focus statement – The problem statement should describe how the pain is an issue for the resident with a focus on functional level, cognitive, and psychosocial well-being.
    • Measurable Objective/Goal – Based on the pain assessment develop resident centered goals aimed at pain control based on the level of pain desirable for the resident to maintain or improve function. For residents who are unable to communicate, focus on eliminating or mitigating behaviors associated with pain.
    • Individualized Interventions: Interventions should include both medications ordered with parameters describing when to administer and non-pharmacological pain management interventions. An interdisciplinary approach involves all members of the care plan team in the development of the care plan interventions, which includes nursing, activities, social service, therapy, the resident, and family/significant other.
    • Evaluation of the Care Plan: The individualized care plan interventions must be implemented in accordance with the care plan and evaluated for effectiveness and ongoing appropriateness.

Join the Proactive team on March 19th as the Documentation in Depth series focuses on Supportive Documentation for Pain Management. This training will equip participants with essential skills, knowledge, and strategies to create supportive and thorough documentation to defend the care provided for individuals experiencing pain. Also mark your calendar for Immediate Jeopardy Risk: Quality of Care on April 9, 2024 where recent examples of IJ level tags will be reviewed with an in depth discussion of how to avoid similar deficiencies. Contact Proactive for QAPI program support including expert review of clinical programs and care planning.