C0700: Short-term Memory OK

Item Rationale

Health-related Quality of Life

• To assess the mental state of residents who cannot be interviewed, an intact 5-minute recall (“short-term memory OK”) indicates greater likelihood of normal cognition.

• An observed “memory problem” should be taken into consideration in Planning for Care.

Planning for Care

• Identified memory problems typically indicate the need for:

— Assessment and treatment of an underlying related medical problem (particularly if this is a new observation) or adverse medication effect, or

— possible evaluation for other problems with thinking

— additional nursing support

— at times frequent prompting during daily activities

— additional support during recreational activities.

Steps for Assessment

1. Determine the resident’s short-term memory status by asking them:

• to describe an event 5 minutes after it occurred if you can validate the resident’s response, or

• to follow through on a direction given 5 minutes earlier.

2. Observe how often the resident has to be re-oriented to an activity or instructions.

3. Staff members also should observe the resident’s cognitive function in varied daily activities.

4. Observations should be made by staff across all shifts and departments and others with close contact with the resident.

5. Ask direct care staff across all shifts and family or significant others about the resident’s short-term memory status.

6. Review the medical record for clues to the resident’s short-term memory during the look-back period.

Coding Instructions

Based on all information collected regarding the resident’s short-term memory during the 7-day look-back period, identify and code according to the most representative level of function.

• Code 0, memory OK: if the resident recalled information after 5 minutes.

• Code 1, memory problem: if the most representative level of function shows the absence of recall after 5 minutes.

Coding Tips

• If the test cannot be conducted (resident will not cooperate, is non-responsive, etc.) and staff members were unable to make a determination based on observing the resident, use the standard “no information” code (a dash, “-”) to indicate that the information is not available because it could not be assessed.

Example

1. A resident has just returned from the activities room where they and other residents were playing bingo. You ask them if they enjoyed themself playing bingo, but they return a blank stare. When you ask them if they were just playing bingo, they say, “no.” Code 1, memory problem.

Coding: C0700, would be coded 1, memory problem.

Rationale: The resident could not recall an event that took place within the past 5 minutes.