Step-by-Step Coding Guide for C0700. Short-term Memory OK

1. Review of Medical Records

Begin by reviewing the resident's medical records, focusing on documentation related to cognitive function, memory assessments, and any clinical notes indicating instances of forgetfulness or memory lapses. Pay attention to records from a variety of sources, including physician notes, nursing assessments, therapy evaluations, and family reports.

2. Understanding Definitions

Short-Term Memory: The ability to recall information that has been learned a few minutes ago.

OK: Indicates that the resident demonstrates an intact ability to remember recent events or information.

3. Coding Instructions

• Code 0, No: If the resident is typically unable to recall recent conversations, instructions learned a few minutes ago, or what was served for their last meal.
• Code 1, Yes: If the resident is typically able to recall recent conversations, instructions from a few minutes ago, and what was served for their last meal without significant difficulty.

4. Coding Tips

• Observe the resident's interactions and responses during conversations and activities to assess their short-term memory capabilities.
• Engage the resident in discussions that require recalling recent events or information to evaluate their memory recall directly.
• Collaborate with other staff members who interact with the resident to gather consistent observations about the resident's short-term memory performance.

5. Documentation

Document specific instances and examples that support your coding decision. Include details such as the resident's ability to remember tasks they were asked to complete, conversations about recent events, or questions about meals and activities.

6. Common Errors to Avoid

• Overlooking Observations: Failing to consider observations from a variety of settings and times of day, which could provide a more accurate assessment of memory function.
• Misinterpreting Behavior: Assuming a resident has poor memory based on isolated incidents without considering the overall pattern of their cognitive function.
• Not Considering Language Barriers: Misattributing memory issues to residents with language or communication barriers.

7. Practical Application

Example Scenario: Mrs. Smith participates in a group activity in the morning and has lunch with her friends at noon. At 2 PM, when asked about the activity and what she had for lunch, she accurately describes the painting activity and remembers having chicken salad for lunch.

Documentation: "Observed Mrs. Smith recall details of the morning activity and her lunch menu accurately during the 2 PM assessment."

Coding: Based on Mrs. Smith's ability to recall recent events accurately, C0700 would be coded as 1, Yes.

The Step-by-Step Coding Guide for item C0700 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.