Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: Pain Factors
Collected For: PAL-02
Definition:Documentation of a comprehensive pain assessment that included pain factors completed within one day of the pain screening.
Suggested Data Collection Question:Is there documentation of a comprehensive pain assessment including pain factors completed within one day of pain screening?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation in the medical record that a comprehensive pain assessment including pain factors was completed within one day of the pain screening.

N (No) There is no documentation that a comprehensive pain assessment including pain factors was completed within one day of the pain screening or unable to determine from the medical record.
Notes for Abstraction:
  • A comprehensive pain assessment includes documentation of factors that relieves or worsens pain. Examples for this component include but are not limited to:
    • Factors that relieve or worsen pain – aggravating or alleviating actions, activities, or positions
      • What increases or decreases your pain?
  • Components of the comprehensive assessment must be documented in the medical record within one day of the pain screening to select "yes". The time frame for documentation is the day of and the day after the pain screening.
  • The comprehensive assessment documentation may be completed by any member of the palliative care core interdisciplinary team. The core interdisciplinary team is comprised of the following: Physician(s); Registered nurse(s) or advanced practice nurse(s); Chaplain(s) or, spiritual care professional(s); Social worker(s).
  • It is possible to include elements of the pain assessment for nonverbal patients. A family report may be used to complete one or more of the components of the comprehensive assessment. Clinical notes about assessment of nonverbal indicators of pain are also acceptable to select “1”. Examples included but are not limited to:
    • Nonverbal indicators of pain include nonverbal sounds such as crying, whining, and groaning; facial expressions, such as grimaces and clenched jaw; and protective body movements or postures such as bracing, guarding, rubbing, or clutching a body part.
    • An assessment that included what relieves/worsens pain for a nonverbal patient may include documentation about actions, activities, or positions that relieve/worsen pain, such as “patient exhibits fewer nonverbal signs of pain when sitting up versus lying down.”
  • Documentation based on whether the clinician made an attempt to gather the information from the patient/family may be used. For example, if, for a nonverbal patient, the clinician asked the family about factors that relieves or worsens pain and the family responded “I’m not sure” or “I don’t know.”
Suggested Data Sources:

  • Palliative care consultation notes
  • Palliative care team progress notes
  • Palliative care initial encounter notes
  • Palliative care admission assessment
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Pain Factors
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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