Step-by-Step Coding Guide for Item Set C0900C: Staff Assessment of Mental Status - Recall Staff Names/Faces

1. Review of Medical Records

Begin with a thorough examination of the resident’s medical and care records, focusing on any documented observations related to cognitive assessments, particularly those regarding memory and recognition abilities. Review previous assessments for baseline comparisons.

2. Understanding Definitions

Recall of Staff Names/Faces: This refers to the resident's ability to remember and correctly identify the names and/or faces of staff members with whom they interact regularly.

3. Coding Instructions

For C0900C, code based on the resident's ability to recall staff names and faces:

• Code "0" if the resident consistently recognizes staff.
• Code "1" if the resident sometimes recognizes staff.
• Code "2" if the resident rarely or never recognizes staff.

4. Coding Tips

• Conduct assessments in a consistent environment to avoid confusion.
• Consider the resident’s comfort and usual interaction times to ensure a more accurate assessment.
• Allow natural interactions to observe recognition over staged testing, if possible.

5. Documentation

Record the assessment results in the resident’s health records, detailing the observed frequency of staff recognition. Note specific instances or patterns observed that support the coding decision.

6. Common Errors to Avoid

• Not accounting for variations in the resident's cognitive function due to time of day, medication effects, or current health status.
• Confusing a resident’s polite nodding or generic responses as recognition.
• Failure to update the assessment when there are significant changes in the resident's cognitive status.

7. Practical Application

Example: Mrs. Jones, a resident, interacts with nursing staff across various shifts. During a casual conversation, observe whether she calls the staff by name or shows signs of recognition like smiling or initiating conversation. If Mrs. Jones consistently recognizes and names her caregivers correctly without prompting, she would be coded "0" for this item. If she shows recognition occasionally or seems unsure, she would be coded "1". If she fails to recognize staff and appears confused or does not interact personally, she would be coded "2".

Please note that the information provided in this guide for MDS 3.0 Item set C0900C 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.