HOPE Guidance Manual v1.02, Item J0900

Timepoint(s) Item Completed

Admission (ADM)

Item-Specific Instructions

• Assess the patient for the presence of pain.

• Item completion should be based on what is determined during the assessment visit and/or included in

the clinical record. Do not use sources external to the clinical record.

• Review the clinical record for information regarding pain screening.

• Consider results of the standardized pain screening tool and any other screening approaches the clinician

used that might include asking the patient about their pain comfort.

• Review all response choices before making a selection.

A. Was the patient screened for pain?

• Code 0, No, if the patient was not screened for pain, and/or there is no documentation that the patient

was screened for pain. Skip to Item J0905, Pain Active Problem.

• Code 1, Yes, if the patient was screened for pain and/or there is documentation that the patient was

screened for pain.

B. Date of first screening for pain

• Enter the date of the first screening for pain.

• It is possible that at the time of completion, multiple pain screenings will be documented in the clinical

record.

• Complete pain screening items based on the first pain screening documented in the clinical record.

C. The patient’s pain severity was: Use Table 4 below to assist with choosing pain severity.

Table 4: Pain Severity Ratings

Code When to Use Scale Equivalent Examples

(Numeric, verbal, visual, staff

observation, or other)

0, None if the patient’s pain severity score was

none.

0 on a 10-point numeric scale.

1, Mild if the patient’s pain severity score was

mild.

1–3 on a 10-point numeric scale.

2, Moderate if the patient’s pain severity score was

moderate.

4–6 on a 10-point numeric scale.

3, Severe if the patient’s pain severity score was

severe.

7–10 on a 10-point numeric scale.

9, Pain not rated if the patient had pain, but the patient’s

pain severity was not assessed or

documented.

D. Type of standardized pain tool used: Use Table 5 to determine the type of standardized pain tool used

for the assessment.

Table 5: Standardized Tools for Pain Assessment

Type of Tool When to Use Scale Type Examples

1, Numeric if a numeric scale was used to conduct

pain screening.

e.g., 10-point scale, the Edmonton

Symptom Assessment System

(ESAS), and Symptom Distress

Scale (McCorkle).

2, Verbal descriptor if a verbal descriptor scale was used to

conduct pain screening.

e.g., the Brief Pain Inventory,

McGill pain questionnaire

(MPQ), and the 6- Point Verbal

Pain Scale.

3, Patient visual if a patient visual scale was used to

conduct pain screening.

e.g., Wong-Baker FACES Pain Scale,

visual analog scale, and a distress

thermometer.

4, Staff observation if a staff observational scale was used to

conduct pain screening.

Select only if a standardized staff

observational scale was used.

(e.g., Pain Assessment in Advanced

Dementia (PAIN-AD), the FLACC

scale, Critical Care Pain Observation

Tool (CPOT) or Checklist of

Nonverbal Pain Indicators (CNPI)).

Type of Tool When to Use Scale Type Examples

9, No standardized tool

used

if no standardized scale was used to

screen for the presence and severity of

pain.

Not Applicable.

Coding Tips

• Select the best response for pain severity based on the pain level at the time of the visit during which the

first screening was performed.

o If a range is provided, such as mild to moderate, report the highest level of severity experienced

during the visit.

• If a non-numeric scale was used to screen the patient for pain, select the pain severity item based on the

standard established for that scale.

o If no standard has been established for that scale, use clinician judgment to categorize severity.