MDS Alert

Your findings in the oral health assessment, necessary for Section L (Dental), provide crucial information for Section J (Pain) and Section K (Swallowing/Nutritional Status), too. Are you catching and noting these flags?

Start With Questions

Beginning your assessment with some questions can point you toward any problems the resident might be aware of, as well as provide some starting points for additional investigation. You want to examine the physical state of the resident’s mouth, as well as make sure that she isn’t experiencing any issues.

Some helpful questions include:

• Are you having any difficulty swallowing? Have you had any problems at the past few meals?
• Does chewing hurt anything? If so, what hurts? Your teeth (or dentures) or gums or tongue?
• Is swallowing easy? If not, does swallowing hurt? When did this start?
• Does chewing or swallowing make you want to cough? If so, do you feel like you need to cough when eating or drinking?

If a resident isn’t verbal or communicative, look into her clinical record to see if there are any indications of mouth pain or swallowing issues. If a resident isn’t self-feeding, pay extra attention to the state of her mouth, to make sure she’s still getting enough fluids for tissues to remain healthy.

Remember: Talk to other team members, across all shifts. If a resident is receiving speech therapy, the therapist should have a deeper understanding of how the resident’s mouth and swallowing are functioning.

Code Across the MDS

Section J: Don’t forget to record any instances of pain in Section J, if a resident responds yes to any of your questions about pain:

• J0300 (Pain Presence),
• J0400 (Pain Frequency),
• J0500B (Pain effect on Function), and
• J0600 (Pain Intensity).

And if the resident isn’t verbal but there are indications of pain, remember to code the responses in the staff assessment for pain:

• J0800 (Indicators of Pain or Possible Pain), and
• J0850 (Frequency of Indicator of Pain or Possible Pain).

Section K: Make sure you record any evidence of swallowing issues, too! Document, with a check mark, this information in these Section K sub-items:

• K0100B (Swallowing Disorder; Holding food in mouth/cheeks or residual food in mouth after meals),
• K0100C (Swallowing Disorder; Coughing or choking during meals or when swallowing medications), and
• K0100D (Complaints of difficulty or pain with swallowing).

Section L: Simply check the box for L0200F (Mouth or facial pain, discomfort or difficulty with chewing).