C0800. Long-term Memory OK, Step-by-Step

Step-by-Step Coding Guide for C0800. Long-term Memory OK

1. Review of Medical Records

• Begin by reviewing the resident's medical records, including physician notes, nursing notes, therapy notes, and any neuropsychological evaluations. Look for documented evidence of long-term memory issues, such as difficulty remembering past personal information (e.g., significant life events, past medical history).

2. Understanding Definitions

• Long-term Memory: The ability to recall information about past events, experiences, and factual information over extended periods, ranging from hours to days to years.

3. Coding Instructions

• Code 0, No: if the resident has demonstrated a significant issue with recalling long-term memory content. This includes forgetting significant portions of their life history or inability to remember key personal information.
• Code 1, Yes: if the resident’s long-term memory seems intact, meaning they can recall their life history, understand their health condition history, and remember significant personal information accurately.

4. Coding Tips

• Observe the resident during various interactions and activities. Engage in conversations that may reveal their ability to recall long-term information.
• Consult with the interdisciplinary team members who may provide insights into the resident's long-term memory status through their interactions.

5. Documentation

• Record any observations and resident or staff statements that support the coding decision. Include specific examples of the resident's ability or inability to recall long-term information.
• Note any inconsistencies in the resident's memory recall over time.

6. Common Errors to Avoid

• Do not solely rely on a single instance of memory lapse to determine long-term memory status.
• Avoid coding based on assumptions or without reviewing the resident's history and current observations.

7. Practical Application

• Example Scenario: Mrs. Smith, an 82-year-old resident, consistently recalls her childhood, names of her children, and major life events during social activities and discussions with staff. However, she sometimes forgets what she had for breakfast. The appropriate code for Mrs. Smith’s long-term memory status would be 1, Yes, as she demonstrates a strong ability to recall long-term information despite some short-term memory lapses.

The Step-by-Step Coding Guide for item C0800 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.