Q&A: A resident answered “no” to having pain during the MDS interview, but documentation shows one episode of pain during the 5-day look-back period. How should I code this?

Rena R. Shephard, MHA, RN, RAC-MT, DNS-CT, QCP-MT

Question: I have a question regarding J0300, "Have you had pain or hurting any time in the past 5 days?"

The resident answers "no,” but the progress notes state that the resident had pain and was given PRN pain medication within the 5-day window.  If the resident did have one episode of pain, but it was resolved with the PRN pain medication.  How would I code this situation?

Answer: With the scripted resident interviews on the MDS, you must code the resident's response regardless of other information you might have. When the CAA triggers, you will have the opportunity to collect all information related to pain and to develop the plan accordingly. If the CAA does not trigger, but pain has been present for the resident according to other parts of the chart, the care plan should still be developed based on all available information that relates to pain in the look-back period.

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