Pain Severity (v2019A1)

Specifications Manual for Joint Commission National Quality Measures (v2019A1)

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Release Notes:
Data Element
Version 2019A1

Name:

Pain Severity

Collected For:

PAL-01, PAL-02

Definition:

Evaluation of the patient for the presence or absence of pain, and its severity using a standardized tool at the time of the palliative care initial encounter.

Question:

What was severity of pain when the patient was first screened for pain during the palliative care initial encounter?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

0 None

1 Mild

2 Moderate

3 Severe

4 Pain severity not able to be rated

5 There is no documentation that the patient was screened for pain, or unable to determine from medical record documentation.

Notes for Abstraction:

A comprehensive pain assessment includes documentation of pain character. Examples for this component include but are not limited to:
- Severity – pain level or intensity rating
  - How severe is your pain now?
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 pain severity for a nonverbal patient may include documentation about intensity of nonverbal expressions of pain (grimaces, winces, and clenched teeth/jaw) or protective body movements (bracing, guarding, rubbing, clutching, or holding of a certain body part/area). It could also include documentation of severity using a nonverbal standardized rating scale.
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 pain character and the family responded “I’m not sure” or “I don’t know.”
Select “0” if documented in the medical record the patient’s pain severity score was none. This would include a score of 0 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient very drowsy; appears to be comfortable during visit. No nonverbal signs of pain observed during the visit.”
Select “1” if documented in the medical record the patient’s pain severity score was mild. This would include a score of 1–3 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient reports 3/10 abdominal pain now; was 6/10 during past 24 hours.” Select “1 Mild” based on the patient’s pain severity rating at the time of the initial encounter.
Select “2” if documented in the medical record the patient’s pain severity score was moderate. This would include a score of 4–6 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient reports he has recently taken a dose of his pain medication, and throughout the visit his pain is reported as 4/10. Patient states he has a history of pain, at its worst pain is 9/10.” Select “2 Moderate” based on the patient’s pain status at the time of the screening.
Select “3” if documented in the medical record the patient’s pain severity score was severe. This would include a score of 7–10 on a 10-point numeric scale or equivalent on verbal, visual, other numeric, or staff observation scale. Example: “patient unable to speak; observed during 20 minute evaluation; pain severity on nonverbal scale moderate to severe.” It is evident that the patient was in pain, and that the clinician evaluated the patient’s pain and noted pain severity. Although the clinical tool is not named, it is still evident that the clinician used a standardized approach or clinical protocol to screen the patient. Select “3 Severe” based on the highest severity of pain at the time of the screening.
Select “4” if documented in the medical record the patient had pain, but the patient’s pain severity was not able to be evaluated by any manner. This would include documentation that staff was unable to rate severity by observation or patient was unable or declined to use a rating scale. Example: “patient intubated and sedated.”
Select “5” if there is no documentation that the patient was screened for pain, or unable to determine from medical record documentation.
Pain screening includes evaluating the patient for presence of pain, and if pain is present, rating of its severity using a standardized tool. A standardized tool is one that (1) has been scientifically tested on a population with characteristics similar to that of the patient being assessed (for example, community-dwelling elderly, non-institutionalized adults with disabilities, etc.), and (2) includes a standard response scale (for example, a scale where patients rate pain from 0-10). The standardized tool must be appropriately administered as indicated in the instructions and must be relevant for the patient's ability.
Examples of standardized numeric scales include, but are not limited to:
- 10-point scale
- Symptom Distress Scale (McCorkle)
- Memorial Symptom Assessment Scale (MSAS)
- Edmonton Symptom Assessment System (ESAS)
Examples of standardized verbal descriptor scales include, but are not limited to:
- Brief Pain Inventory
- McGill pain questionnaire
- 6-point Verbal Pain Scale
Examples of standardized patient visual scales include, but are not limited to:
- Wong-Baker FACES Pain Scale
- Visual analog scale
- Distress thermometer
Examples of standardized staff observation scales include, but are not limited to:
- Critical Care Pain Observation Tool (CPOT)
- Checklist of Nonverbal Pain Indicators (CNPI)
- Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
- Pain Assessment in Advanced Dementia (PAIN-AD)
It is possible that at the time of the palliative care initial encounter there will have been multiple pain screenings documented in the clinical record. For purposes of this measure use the first pain screening that appears during the palliative care initial encounter.
If a range is provided, such as mild to moderate, select the highest level of severity recorded during the initial encounter.
If a non-numeric scale was used to screen the patient for pain, select the pain severity based on the standard established for that scale. If no standard has been established for that scale, the organization must establish the standard to categorize severity.
If documentation in the patient’s medical record indicates the patient was assessed clinically and was found to have no pain, but no standardized pain tool was used to screen the patient, select “0, None”.

Suggested Data Sources:

Palliative care consultation notes
Palliative care team progress notes
Palliative care initial encounter notes
Palliative care admission assessment

Additional Notes:

Notes adapted from: Guidance Manual for Completion of the Hospice Item Set (HIS), Centers for Medicare and Medicaid Services, Hospice Quality Reporting Program, V 1.02 Effective June 28, 2015

Guidelines for Abstraction:

Inclusion	Exclusion
None	None

Specifications Manual for Joint Commission National Quality Measures (v2019A1)
Discharges 10-01-19 through 12-31-19 (4Q19)

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