C0400: Recall

Step-by-Step Coding Guide for C0400: Recall

1. Review of Medical Records

• Objective: To gather baseline information on the resident's cognitive status, including any previously diagnosed memory impairments or conditions affecting recall.
• Process: Review the resident's medical records for documentation related to cognitive assessments, diagnoses of dementia or memory impairments, and any relevant notes from healthcare providers about the resident's recall abilities.

2. Understanding Definitions

• Recall: Refers to the ability of an individual to remember information that was previously presented to them.
• Immediate Recall: The capacity to recall information immediately after it is presented.
• Temporal Orientation: The ability to correctly state the current date, month, and year.

3. Coding Instructions

• Conduct the Brief Interview for Mental Status (BIMS) as part of the cognitive assessment.

• Ask the resident the three items (C0200-C0400) to assess recall and temporal orientation.

• For C0400 specifically, ask the resident to recall the words you previously provided (sock, blue, bed). Allow the resident to respond without prompts initially.

  Coding for C0400:

  • Code 0: No recall.
  • Code 1: Able to recall one word.
  • Code 2: Able to recall two words.
  • Code 3: Able to recall all three words.

4. Coding Tips

• Ensure the environment is quiet and free from distractions during the interview.
• Use a calm and patient approach, giving the resident sufficient time to respond.
• Do not prompt or give hints to the answers when assessing recall unless necessary for clarifying purposes.

5. Documentation

• Document the resident's responses to the recall items accurately in their medical record.
• Include any observations about the resident's effort, attention, and any external factors that might have influenced their performance.

6. Common Errors to Avoid

• Leading the resident to the answer or providing prompts that could aid recall.
• Not accounting for hearing or speech impairments that might affect the resident's ability to understand the questions or respond correctly.
• Failing to document the assessment thoroughly and accurately.

7. Practical Application

• Use the results of the recall assessment to inform care planning, especially for residents with cognitive impairments.
• Tailor activities and interventions to the resident's cognitive abilities, promoting engagement and stimulation.

The Step-by-Step Coding Guide for item C0400 in MDS 3.0 Section C 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.