Step-by-Step Coding Guide for B0700: Makes Self Understood

1. Review of Medical Record

• Objective: Examine the resident's medical records to identify any noted difficulties or abilities in making themselves understood.
• Key Points:
  • Look for notes from speech-language pathologists, nurses, and physicians.
  • Check for any diagnoses that might affect communication, like stroke or neurological disorders.

2. Understanding the Definition

• Objective: Clarify what 'Makes Self Understood' encompasses.
• Key Points:
  • It refers to the resident's ability to communicate requests, needs, opinions, and conduct social conversation in their primary language.
  • This includes speech, writing, sign language, gestures, or a combination.

3. Coding Instructions

• Objective: Accurately code the resident's ability to make themselves understood.
• Key Points:
  • Code 0 (Understood): Clear expression of requests and ideas.
  • Code 1 (Usually Understood): Some difficulty, but can communicate if prompted or given time.
  • Code 2 (Sometimes Understood): Limited ability, can express basic needs.
  • Code 3 (Rarely/Never Understood): Extremely limited understanding, relies on interpretation of sounds or body language.

4. Coding Tips

• Objective: Ensure precision in coding.
• Key Points:
  • Engage in direct conversation with the resident.
  • Observe interactions with others in different settings.
  • Consult with caregivers and speech-language pathologists for additional insights.

5. Documentation

• Objective: Record your findings and coding rationale.
• Key Points:
  • Note specific examples that justify the chosen code.
  • Include observations from staff and family if applicable.

6. Common Errors to Avoid

• Objective: Identify and prevent common mistakes in coding B0700.
• Key Points:
  • Avoid assumptions based on the resident's medical condition without direct assessment.
  • Don’t overlook the need for prompting or extra time in residents who seem to communicate well initially.

7. Practical Application

• Objective: Apply your understanding in a real-world context.
• Key Points:
  • Use role-playing scenarios to practice coding.
  • Discuss case studies in team meetings for broader understanding.

The Step-by-Step Coding Guide for item B0700 in MDS 3.0 Section B is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.