Hospice Composite Measure: Pain in Verbal, Nonverbal, or Cognitively Impaired Patients


hospice aide uses hospice software to help patients

According to the Hospice Quality Reporting Program: Specifications for the Hospice Item Set-Based Quality Measures, patients and caregivers rate pain management as a high priority when living with life-limiting illnesses. The consequences of inadequate screening, assessment, and treatment for pain include physical and existential suffering, diminished functional status, and development of depression. Therefore, comprehensive pain assessment is a critical quality measure for hospice agencies and should be documented in the hospice software.

Pain Assessment in the Hospice Software

The Pain Assessment Quality Measure is looking at all patients who screened as having pain on their initial nursing assessment and received a comprehensive assessment of pain within one day of the screening. For the comprehensive pain assessment to be counted as completed, five of the seven pain characteristics need to be assessed by the clinician and documented in the hospice software. The seven characteristics are:

  • Location: where the pain is located
  • Severity: how much pain is present
  • Character: description of the pain
  • Duration: how long does the pain last
  • Frequency: how often does the pain occur
  • What relieves or worsens pain
  • Effect on function or quality of life

If fewer than five of the seven characteristics are assessed – or the nurse attempts to assess fewer than five of the characteristics – this quality measure will not be met. A comprehensive pain assessment that does not occur within one day of the pain screening would also not meet criteria for the quality measure.

Verbal Assessment in the Hospice Software

If a patient did not have pain during the pain screening, then the patient will not be counted for presence of a comprehensive pain assessment for the quality measure. However, if the patient did not have pain during the initial screening but does have scheduled pain medications and pain is an active problem for the patient, it is best practice to complete the comprehensive pain assessment for these patients.

Nonverbal Assessment in the Hospice Software

With a verbal patient, asking the questions and obtaining information is simpler. If a patient is not certain of the answer but the nurse attempted to gather the information, document the response of the patient in the hospice software and mark that the aspect of the comprehensive pain assessment was completed.

It is more of a challenge to include all elements of a comprehensive pain assessment in HIS question J0910C for nonverbal patients. A caregiver report about any of the pain characteristics is acceptable. It is also important to ask the caregiver about the patient’s recent pain history when completing the comprehensive pain assessment in the hospice software. Clinical documentation about the nurse’s observation of nonverbal indicators of pain for any of the above characteristics is also acceptable.

The HIS Manual version 2.01 gives examples of a comprehensive pain assessment for a nonverbal patient that are an excellent teaching resource for clinicians. Nonverbal indicators of pain include sounds such as crying, whining and groaning; facial expressions, such as grimacing or frowning; and protective body movements such as guarding or clutching a body part. Pain location assessment for a nonverbal patient may include documentation such as “patient cried and winced when clinician touched their right arm.”

Pain severity assessment for a nonverbal patient may include documentation about intensity of nonverbal expressions of pain or protective body movements such as bracing and guarding. It could also include documentation of severity using a nonverbal standardized rating scale, such as the Wong Baker or PAINAD scales. Pain duration assessment for a nonverbal patient may include documentation about how long a patient exhibits any nonverbal cues of pain, such as “patient had grimace and crying while holding right arm for one hour.” Pain frequency for a nonverbal patient may include documentation about how often a patient exhibits any nonverbal cues of pain, including constantly, daily, or during certain activities.

An assessment that includes what relieves or worsens pain for a nonverbal patient may include documentation about activities or positions that relieve or worsen pain, such as “patient exhibits increased nonverbal signs of pain when sitting in chair.” An assessment that includes pain’s effect on function or quality of life for a nonverbal patient may include documentation about change in patient activity, such as “caregiver reports that patient is no longer able to sit up in chair without bracing and guarding.”

If you ask a family or caregiver about any of the aspects of the comprehensive pain assessment and the family/caregiver does not know the answer, mark that you assessed these areas, and include documentation in your narrative that you asked these questions and indicate the lack of response. It is important to document the attempt in the hospice software to gather the information and take credit for your work.

Remember, if you are the person responsible for approving the Admission HIS prior to submission, take the time to read the clinical documentation in the hospice software prior to submission. The clinician may have documented items that are key to the comprehensive pain assessment measure in the narrative sections of the notes, and HIS does allow for changing of the responses in the HIS document based on information found in other areas of the clinical documentation.

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