Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Posted: 9/13/2019
Home » Pain Factors

Release Notes:
Data Element
Version 2020A1

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.
Question:Is there documentation of a comprehensive pain assessment including pain factors completed within one day of pain screening?
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
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.