Step-by-Step Coding Guide for Item Set C0300C: BIMS Res Interview: Able to Report Correct Day of the Week

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s cognitive function and orientation.
• Steps:
  1. Collect Information: Review the resident’s medical records, including previous cognitive assessments, nursing notes, and physician evaluations.
  2. Identify Cognitive Status: Look for documented evidence of the resident’s cognitive status and any noted orientation issues.
  3. Confirm Consistency: Verify that the resident’s orientation to time has been consistently assessed and documented.

2. Understanding Definitions

• BIMS (Brief Interview for Mental Status): A structured cognitive assessment used to evaluate a resident's mental status, focusing on orientation and recall abilities.
• Correct Day of the Week: The ability of the resident to accurately identify the current day of the week during the BIMS interview.

3. Coding Instructions

• Steps:
  1. Conduct the Interview: Ask the resident, “What day of the week is it today?” during the BIMS interview.
  2. Record the Response: Document the resident’s response verbatim.
  3. Evaluate Accuracy: Determine if the resident’s response is correct. The correct response must include the full name of the current day (e.g., “Tuesday” for Tuesday).
  4. Code Appropriately: Code C0300C as "1" if the resident correctly identifies the day of the week, and "0" if the resident does not.

4. Coding Tips

• Clarify Questions: If the resident seems confused, clarify the question without leading them to the correct answer.
• Provide a Comfortable Setting: Ensure the resident is comfortable and free from distractions during the interview.
• Consistency: Perform the interview consistently each time to ensure accuracy and reliability of responses.

5. Documentation

• Required:
  • Interview Notes: Record the exact question asked and the resident’s verbatim response.
  • Assessment Date: Document the date and time of the interview.
  • Observer Notes: Include any relevant observations about the resident’s behavior or condition during the interview.
  • Outcome: Clearly document the outcome of the coding (1 for correct, 0 for incorrect).

6. Common Errors to Avoid

• Leading Questions: Avoid leading the resident to the correct answer. The resident must identify the day independently.
• Inconsistent Timing: Conduct the interview at a consistent time to avoid confusion and ensure the resident is oriented.
• Inadequate Documentation: Ensure all aspects of the interview are thoroughly documented, including any contextual factors that might affect the resident's response.

7. Practical Application

• Example:
  • Resident Profile: Mary, an 82-year-old resident with mild cognitive impairment, is typically alert and oriented.
  • Steps Taken:
    1. Prepare the Setting: The interviewer ensures a quiet, comfortable environment for the interview.
    2. Conduct the Interview: The interviewer asks, “Mary, can you tell me what day of the week it is today?”
    3. Record the Response: Mary responds, “It’s Tuesday.”
    4. Evaluate and Code: Since Mary’s response is correct, the interviewer codes C0300C as "1".
  • Outcome: Mary’s cognitive status is accurately documented, reflecting her ability to report the correct day of the week.

Please note that the information provided in this guide for MDS 3.0 Item set C0300C was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.