Step-by-Step Coding Guide for Item Set C0400A: BIMS Res Interview: Able to Recall "Sock"

1. Review of Medical Records

• Objective: Accurately assess and document the resident's ability to recall the word "sock" during the Brief Interview for Mental Status (BIMS) assessment.
• Steps:
  1. Collect Information: Gather the resident’s medical records, including previous cognitive assessments, care plans, and notes from interdisciplinary team members.
  2. Identify Documentation of Cognitive Status: Look for documented instances where the resident’s cognitive abilities were assessed or observed, particularly during the BIMS interview.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• BIMS (Brief Interview for Mental Status): A standardized tool used to assess cognitive function in residents. It includes questions to test memory and recall.
• Recall: The ability to remember and repeat the word "sock" after a short delay.
• Key Points:
  • Three-Word Recall Test: Typically includes the words "sock," "blue," and "bed."
  • Scoring: Based on the resident’s ability to correctly recall each word after a delay.

3. Coding Instructions

• Steps:
  1. Administer the BIMS: Conduct the BIMS interview according to the standardized procedure, ensuring the resident is comfortable and understands the instructions.
  2. Test Recall: After presenting the three words (e.g., "sock," "blue," "bed"), ask the resident to recall them after a brief interval.
  3. Code Appropriately: Enter the appropriate code for item set C0400A based on the resident’s response:
     • 0: No, the resident was not able to recall the word "sock."
     • 1: Yes, the resident was able to recall the word "sock."

4. Coding Tips

• Accurate Administration: Ensure the BIMS interview is administered correctly, following all standard protocols.
• Consistent Terminology: Use consistent terminology and phrasing when documenting the resident’s ability to recall the word "sock."
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • BIMS Assessment Form: The standardized form used to record the results of the BIMS interview.
  • Nursing Notes: Detailed notes from nursing staff documenting the administration and results of the BIMS interview.
  • Care Plans: Including any interventions or strategies to support cognitive function based on the BIMS results.
  • Previous Cognitive Assessments: Any previous assessments that have documented the resident’s cognitive abilities.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s response during the BIMS interview.
• Incomplete Documentation: Make sure all relevant notes and assessments are included to support the documented ability to recall the word "sock."
• Assumptions: Do not assume the resident’s ability without proper documentation and verification; always follow the standardized BIMS procedure.

7. Practical Application

• Example:
  • Resident Profile: Jane, a 78-year-old resident, was assessed using the BIMS interview during her quarterly review.
  • Steps:
    1. Administer BIMS: The nurse conducts the BIMS interview, presenting the words "sock," "blue," and "bed" to Jane.
    2. Test Recall: After a short delay, the nurse asks Jane to recall the words. Jane successfully recalls "sock" and "bed," but not "blue."
    3. Document and Code: The nurse documents Jane’s responses and codes C0400A as "1" for being able to recall "sock."
  • Outcome: Jane’s ability to recall the word "sock" is accurately documented and coded, contributing to her overall cognitive assessment.

Please note that the information provided in this guide for MDS 3.0 Item set C0400A 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.