Step-by-Step Coding Guide for Item Set C0900A: Staff Assessment Mental Status - Recall Current Season

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s ability to recall the current season.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, nursing notes, cognitive assessments, and previous evaluations.
  2. Identify Cognitive Status Documentation: Look for documented instances that assess the resident’s cognitive status, particularly their ability to recall the current season.
  3. Confirm Details: Verify the consistency of these observations through various sources within the medical records.

2. Understanding Definitions

• Recall Current Season: The ability of the resident to correctly identify the present season (spring, summer, fall, or winter) during a cognitive assessment.
• Mental Status Assessment: An evaluation conducted by staff to determine the resident’s cognitive functioning, including memory and orientation.

3. Coding Instructions

• Steps:
  1. Conduct Assessment: During the cognitive assessment, ask the resident to recall the current season.
  2. Evaluate Response: Determine if the resident’s response is correct or incorrect.
  3. Code Appropriately: Use the following scale to code the resident’s response:
     • 0: Resident is unable to recall the current season or gives an incorrect response.
     • 1: Resident correctly recalls the current season.

4. Coding Tips

• Accurate Questioning: Ensure the question about the current season is asked clearly and in a way the resident can understand.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s response.
• Consult Cognitive Assessments: If there is any uncertainty, review additional cognitive assessments or consult with cognitive specialists.

5. Documentation

• Required:
  • Assessment Notes: Document the cognitive assessment, including the specific question about the current season and the resident’s response.
  • Staff Reports: Include reports from staff members detailing their observations and interactions with the resident regarding the cognitive assessment.
  • Assessment Summary: Summarize the resident’s cognitive status in the assessment records, highlighting their ability to recall the current season.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s response to the question about the current season.
• Incomplete Documentation: Make sure all relevant details about the cognitive assessment are thoroughly documented.
• Assumptions: Do not assume the resident’s cognitive abilities without proper documentation and observation.

7. Practical Application

• Example:
  • Resident Profile: Alice, an 85-year-old resident, is being assessed for her cognitive function.
  • Steps:
    1. Conduct Assessment: The nurse asks Alice to recall the current season during a cognitive assessment.
    2. Evaluate Response: Alice correctly identifies the current season as fall.
    3. Document and Code: The nurse documents Alice’s correct response in her records and codes C0900A as "1".
  • Outcome: Alice’s ability to recall the current season is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set C0900A 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.