HOPE Guidance Manual v1.02, Item J0910

Timepoint(s) Item Completed

Admission (ADM)

Item-Specific Instructions

• A comprehensive pain assessment should address multiple aspects of pain, beyond a determination of

the pain presence and severity.

• For any of the seven characteristics included in the pain assessment, select response options based on

whether the clinician made an attempt to gather the information from the patient/caregiver.

o For example, if, for a nonverbal patient, the clinician asked the family/caregiver about pain location

and the family/caregiver responded, “I’m not sure” or “I don’t know,” 01, Location should be

checked because the clinician attempted to gather the information.

Coding Tips

• It is possible to include elements of the pain assessment for nonverbal patients.

o A caregiver report about any of the listed pain characteristics is acceptable.

o Clinical notes about assessment of nonverbal indicators of pain for any of these characteristics are

also acceptable.

Nonverbal Indicators

• Nonverbal indicators of pain include:

o Nonverbal sounds such as crying, whining, and groaning.

o Facial expressions, such as grimacing and clenching the jaw.

o Protective body movements or postures such as bracing, guarding, rubbing, or clutching a body part.

Nonverbal Assessment Documentation

The table below, Table 6, provides examples of documentation for the various pain characteristics.

Table 6 : Nonverbal Pain Characteristics

Pain

Characteristic

Examples

Location An account of patient exhibiting nonverbal cues of pain for a specific

location on the body, (e.g., “Patient grimaced and shouted when

clinician touched their right leg.”).

Severity Description of the intensity of nonverbal expression, e.g., results of a

nonverbal standardized rating scale.

Duration Details about how long a patient exhibits any nonverbal cues, (e.g.,

“Patient cradled right arm through the entire visit.”).

Frequency A report of how often a patient exhibits any nonverbal cues of pain.

What

relieves/worsens

Details of actions, activities, positions that relieve/worsen pain, (e.g.,

“Patient exhibits fewer nonverbal signs of pain when sitting versus

lying down.”).

Effect on function

or quality of life

Notes explaining a change in patient activity, (e.g., “Family/caregiver

reports that the patient is no longer able to sit up in bed without

moaning”).

Examples for J0900, J0905 and J0910

1. The clinical note dated 11-12-2025 indicates the patient reported no pain and there were no complaints

from patient or family. The patient reported recently taking a dose of pain medication. Patient reported a

history of dull, aching pain in the lower abdomen that comes and goes intermittently, and at its worst,

pain is 6/10. Historically, pain is worse when the patient walks and pain is better when lying down.

Coding: See Table 7 for the coding answers to example 1.

Table 7: Example 1 Coding Answers

Data Element (or

Item)

Detail Correct Code or Response

J0900A Was the patient screened for pain? 1, Yes

J0900B Date of first screening for pain: Enter 11-12-2025

J0900C The patient’s pain severity was: 0, None

J0900D Type of Standardized pain tool used: 9, No standardized tool used

J0905 Pain Active Problem: 1, Yes

J0910A Was a comprehensive pain assessment

done?

1, Yes

J0910B Date of comprehensive pain

assessment:

Enter 11-12-2025

J0910C Comprehensive pain assessment

included:

Check:

• 1, Location (lower abdomen)

• 2, Severity (currently not in pain, but

at its worst, pain is 6/10)

• 3, Character (dull, aching pain)

• 5, Frequency (intermittent)

• 6, What relieves/worsens pain (worse

when patient walks and pain is better

when lying down)

Rationale:

Item J0900. Pain Screening should be completed based on the patient’s pain status and assessment at the

time of the screening clinical encounter. This means that, although the patient reported a history of pain,

item J0900 should be completed based on the clinician’s assessment that the patient was not in any pain at

the time of the visit. Additionally, although there was no standardized pain tool used to screen the patient at

the time of the screening clinical encounter, it is evident that the clinician evaluated the patient and

determined the patient was not in any pain. The correct course of action is to complete J0900A-D.

Item J0905. Pain Active Problem considers factors beyond pain severity at the time of the screening clinical

encounter, such as historical report of pain or report of recent symptoms. In this situation, because the

patient has a history of pain, it is clinically appropriate for the clinician to consider pain to be an active

problem for the patient, and code “1, Yes” for Item J0905. Pain Active Problem.

Since pain is an active problem for the patient, it is clinically appropriate for the clinician to complete a

comprehensive pain assessment (even though the patient was not in pain at the time of the pain screening).

Because at least one of the seven characteristics of a comprehensive pain assessment were clearly

documented, code “1, Yes” for J0910A and continue to J0910B-J0910C, coding based on documentation

found in the clinical record.

2. The clinical note dated 11-12-2025 indicates the patient is unable to speak, was observed during 20-minute

evaluation, and had pain severity on a nonverbal scale of moderate to severe. The clinician interviewed the

family about the patient’s distress. The family stated the patient had been moaning all morning and rarely

looked comfortable. The family stated the patient often clutches the lower abdomen when touched. The

family also reported they are unable to move the patient because of signs of distress when turning. The

family was uncertain about factors that make pain better.

Coding: See Table 8 for the coding answers to example 2.

Table 8: Example 2 Coding Answers

Data Element

(or Item)

Detail Correct Code or Response

J0900A Was the patient screened for pain? 1, Yes

J0900B Date of first screening for pain: Enter 11-12-2025

J0900C The patient’s pain severity was: 3, Severe

J0900D Type of Standardized pain tool used: 4, Staff observation

J0905 Pain Active Problem: 1, Yes

J0910A Was a comprehensive pain assessment

done?

1, Yes

J0910B Date of comprehensive pain

assessment:

Enter 11-12-2025

J0910C Comprehensive pain assessment

included:

Check:

• 1, Location (clutching lower abdomen)

• 2, Severity (pain severity on nonverbal

scale moderate to severe)

• 4, Duration (patient had been moaning all

morning)

• 5, Frequency (rarely looked comfortable)

• 6, What relieves/worsens pain (family

uncertain)

• 7, Effect on function or quality of life

(unable to move because of distress)

Rationale:

Item J0900. Pain Screening should be completed based on the patient’s pain status and assessment at the

time of the screening clinical encounter. 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. For

J0900C, the correct course of action is to code “3, Severe,” based on the highest severity of pain at the time

of the visit.

For Item J0905, clinical documentation that the patient was in pain at the time of the screening visit is

evidence that pain is an active problem for the patient.

For Item J0910, because at least one of the seven characteristics of a comprehensive pain assessment were

clearly documented in the patient’s clinical record, code “1, Yes” for J0910A and continue to J0910B-J0910C, selecting responses based on documentation in the clinical record. Even though the family stated

they were not sure what made the pain better or worse, “6, What relieves/worsens pain” can still be

checked because there was documentation that the clinician asked about what relieves or worsens pain.

3. Clinical documentation dated 11-14-2025 shows the patient is very drowsy but appears comfortable during

the visit. No nonverbal signs of pain observed during the visit. However, the patient’s family reported that

the patient is not allowing necessary dressing changes or incontinence/skin care because the patient cannot

tolerate the pain that each intervention causes. The patient’s family explained to the clinician that the patient

loudly moans/grimaces during weekly dressing changes and incontinence/skin care about six times per day

and that now the patient won’t let them do any more dressing changes or skin care. The family explained

sometimes it was helpful to play music and talk to the patient to try to distract them during dressing changes

and skin care, and, once the dressing change/skin care has been completed, the patient no longer appears to

be in pain. Family reports the patient has no other pain except that caused by dressing and/or

incontinence/skin care interventions.

Coding: See Table 9 for the coding answers to example 3.

Table 9: Example 3 Coding Answers

Data Element

(or Item)

Detail Correct Code or Response

J0900A Was the patient screened for pain? 1, Yes

J0900B Date of first screening for pain: Enter 11-14-2025

J0900C The patient’s pain severity was: 0, None

J0900D Type of Standardized pain tool used: 9, No standardized tool used

J0905 Pain Active Problem: 1, Yes

J0910A Was a comprehensive pain assessment

done?

1, Yes

J0910B Date of comprehensive pain

assessment:

Enter 11-14-2025

J0910C Comprehensive pain assessment

included:

Check:

• 2, Severity (loudly moans/grimaces)

• 4, Duration (throughout dressing change/skin

care and that once the dressing change/skin

care is completed, the patient no longer

appears to be in pain)

• 5, Frequency (during weekly dressing

changes and incontinence/skin care about six

times per day)

• 6, What relieves/worsens pain (dressing

changes/skin care makes pain worse and

playing music and distraction makes pain

better)

• 7, Effect on function or quality of life (patient

no longer allowing dressing changes or skin

care)

Rationale:

Item J0900. Pain Screening should be completed based on the patient’s pain status at the time of the

screening clinical encounter. This means, although the family reported the patient experiences pain

during dressing changes/skin care, item J0900 should be completed based on the clinician’s assessment

that the patient was not in any pain at the time of the screening clinical encounter. Although there was

no standardized pain tool used to screen the patient, it is evident the clinician evaluated the patient and

determined the patient was not in any pain at the time of the screening.

For Item J0905, although the patient family reports no pain other than pain caused during dressing

changes and/or incontinence/skin care, it is evident that pain is interfering with clinical care and

potentially affecting the patient’s quality of life. Thus, in this situation, pain is considered an active

problem.

For Item J0910, since pain is an active problem for the patient, it is clinically appropriate for the

clinician to complete a comprehensive pain assessment (even though the patient was not in pain at the

time of the pain screening). Clinical documentation indicates a comprehensive pain assessment was

performed using a standardized approach or clinical protocol including observation, clinical judgment,

and care giver interview to identify the presence of at least one of the seven characteristics.