Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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MDS Lookup
Indicators of Pain
Item Rationale
Matrix review
4 matrix group(s) are already attached for review on this item.
Answer coverage
5 governed answer row(s) are attached for this item.
Answer Codes
A
Nonverbal sounds
Governed answer row attached.
B
Vocal complaints of pain
Governed answer row attached.
C
Facial expressions
Governed answer row attached.
D
Protective body movements or postures
Governed answer row attached.
Z
None of these signs observed or documented
Governed answer row attached.
What this item is
Item Rationale
When to use it
Use this item when the facility is completing content tied to Section J and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page J-20
- CMS exact locator: Manual page J-20
- This item has 5 governed answer row(s) attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page J-20
CMS exact locator
Manual page J-20
Full CMS Text
Item Rationale
Health-related Quality of Life
Residents who cannot verbally communicate about their pain are at particularly high risk for under-detection and undertreatment of pain. Severe cognitive impairment may affect the ability of residents to verbally communicate, thus limiting the availability of self-reported information about pain. In this population, fewer complaints may not mean less pain. Individuals who are unable to verbally communicate may be more likely to use alternative methods of expression to communicate their pain. Even in this population some verbal complaints of pain may be made and should be taken seriously.
Planning for Care
Consistent approach to observation improves the accuracy of pain assessment for residents who are unable to verbally communicate their pain. Particular attention should be paid to using the indicators of pain during activities when pain is most likely to be demonstrated (e.g., bathing, transferring, dressing, walking and potentially during eating). Staff must carefully monitor, track, and document any possible signs and symptoms of pain. Identification of these pain indicators can: — provide a basis for more comprehensive pain assessment, — provide a basis for determining appropriate treatment, and — provide a basis for ongoing monitoring of pain presence and treatment response. If pain indicators are present, assessment should identify aggravating/alleviating factors related to pain.
Steps for Assessment
1. Review the medical record for documentation of each indicator of pain listed in J0800 that occurred in the
last 5 days. If the record documents the presence of any of the signs and symptoms listed, confirm your record review with the direct care staff on all shifts who work most closely with the resident during activities of daily living (ADL).
2. Interview staff because the medical record may fail to
note all observable pain behaviors. For any indicators that were not noted as present in medical record review, interview direct care staff on all shifts who work with the resident during ADL. Ask directly about the presence of each indicator that was not noted as being present in the record.
3. Observe resident during care activities. If you observe
additional indicators of pain in the last 5 days code the corresponding items. Observations for pain indicators may be more sensitive if the resident is observed during ADL, or wound care.
Coding Instructions
Check all that apply in the last 5 days based on staff observation of pain indicators. If the medical record review and the interview with direct care providers and observation on all shifts provide no evidence of pain indicators, Check J0800Z, None of these signs observed or documented, and proceed to the Shortness of Breath item (J1100). Check J0800A, nonverbal sounds: included but not limited to if crying, whining, gasping, moaning, or groaning were observed or reported in the last 5 days. Check J0800B, vocal complaints of pain: included but not limited to if the resident was observed to or reported to have made vocal complaints of pain (e.g. “that hurts,” “ouch,” or “stop”) in the last 5 days. Check J0800C, facial expressions: included but not limited to if grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw were observed or reported in the last 5 days. Check J0800D, protective body movements or postures: included but not limited to if bracing, guarding, rubbing or massaging a body part/area, or clutching or holding a body part during movement were observed or reported in the last 5 days.
DEFINITIONS
NON VERBAL SOUNDS e.g., crying, whining, gasping, moaning, groaning or other audible indications associated with pain. VOCAL COMPLAINTS OF PAIN e.g., “That hurts,” “ouch,” “stop,” etc. FACIAL EXPRESSIONS THAT MAY BE INDICATORS OF PAIN e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw, etc. PROTECTIVE BODY MOVEMENTS OR POSTURES e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement, etc. Check J0800Z, none of these signs observed or documented: if none of these signs were observed or reported in the last 5 days.
Coding Tips
Behavior change, depressed mood, rejection of care and decreased activity participation may be related to pain. These behaviors and symptoms are identified in other sections and not reported here as pain screening items. However, the contribution of pain should be considered when following up on those symptoms and behaviors.
Examples
1. Resident P has advanced dementia and is unable to verbally communicate. A note in their
medical record documents that they have been awake during the last night crying and rubbing their elbow. When you go to their room to interview the certified nurse aide (CNA) caring for them, you observe Resident P grimacing and clenching their teeth. The CNA reports that they have been moaning and said “ouch” when the CNA tried to move their arm.
Coding: Nonverbal Sounds item (J0800A); Vocal Complaints of Pain item (J0800B);
Facial Expressions item (J0800C); and Protective Body Movements or Postures item (J0800D), would be checked.
Rationale: Resident P has demonstrated vocal complaints of pain (ouch), nonverbal
sounds (crying and moaning), facial expression of pain (grimacing and clenched teeth), and protective body movements (rubbing their elbow).
2. Resident M has end-stage Parkinson’s disease and is unable to verbally communicate. There is
no documentation of pain in their medical record in the last 5 days. The CNAs caring for them report that on some mornings they moan and wince when their arms and legs are moved during morning care. During direct observation, you note that Resident M cries and attempts to pull their hand away when the CNA tries to open the contracted hand to wash it.
Coding: Nonverbal Sounds items (J0800A); Facial Expressions item (J0800C); and
Protective Body Movements or Postures item (J0800D), would be checked.
Rationale: Resident M has demonstrated nonverbal sounds (crying, moaning); facial
expression of pain (wince), and protective body movements (attempt to withdraw).
3. Resident E has been unable to verbally communicate following a massive cerebrovascular
accident (CVA) several months ago and has a Stage 3 pressure ulcer. There is no documentation of pain in their medical record. The CNA who cares for them reports that they do not seem to have any pain. You observe the resident during their pressure ulcer dressing change. During the treatment, you observe groaning, facial grimaces, and a wrinkled forehead.
Coding: Nonverbal Sounds item (J0800A), and Facial Expressions item (J0800C),
would be checked.
Rationale: The resident has demonstrated nonverbal sounds (groaning) and facial
expression of pain (wrinkled forehead and grimacing).
4. Resident S is in a persistent vegetative state following a traumatic brain injury. They are
unable to verbally communicate. There is no documentation of pain in their medical record in the last 5 days. The CNA reports that they appear comfortable whenever the CNA cares for them. You observe the CNA providing morning care and transferring them from bed to chair. No pain indicators are observed at any time.
Coding: None of These Signs Observed or Documented item (J0800Z), would be
checked.
Rationale: All steps for the assessment have been followed and no pain indicators have
been documented, reported or directly observed.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
Care Area Triggers
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Administrative (Tech Need / Edits / Processing)
Marker: +
supporting item
Locator: MDS Item Matrix v1.20.1 v4
Swing Bed Subsets
SP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4