Many of you have chosen pain as an Advancing Excellence goal. Section J2 addresses the frequency and intensity of pain. By not only correctly coding this section, but also looking at the cause and effect of the resident’s pain you will be able to achieve the advancing excellence in care that you are striving for.

Have you ever written off a resident’s complaint of pain because it didn’t fit the “norm” or they are always complaining? I remember being in the hospital following a surgery and telling the nurse that I was having a lot of pain. Her response to me was that most people having this surgery did not have a lot of pain and essentially to just “buck up”. If the nurse had investigated my complaint, she would have found that I had a huge hematoma that needed attention.

Make it a common practice to ask your residents as you care for them if they are having pain. Take their complaints seriously and investigate the cause of their pain. If this is someone who can not verbalize, then observe for facial expressions, moaning, holding of the head, rubbing of joint or increased behaviors. All staff should be on the look out for indicators of pain. Code J2b. with the highest intensity of pain that the resident has experienced in the last 7 days. If a resident refused range of motion, ADL’s, therapy or activities because of pain then you should consider their pain as horrible or excruciating. Coding is based on the resident’s perception of their pain not yours.

If you have determined that the resident had pain in the last seven days, now look at ways to manage their pain. Involve staff in exploring pain relieving techniques that will help with the resident’s pain. Be creative—back rubs, warm baths, soothing music, aroma therapy. As a team you will be able to come up with many more interventions that will work. Above all else listen to your resident’s verbal and non-verbal complaints of pain and take them seriously.

By: Janet Tuttle, RN, RAC-C
ABCM Corporation