Step-by-Step Coding Guide for Item Set C0900D: Staff Assessment Mental Status - Recall in Nursing Home

1. Review of Medical Records

• Objective: To evaluate the resident's ability to recall whether they are in a nursing home.
• Process:
  • Assessment Records: Review records from previous cognitive assessments and mental status examinations.
  • Care Plans: Check the resident's care plan for any documented cognitive impairments or interventions.
  • Nursing and Care Staff Notes: Look for notes on the resident's cognitive status, particularly regarding orientation and memory.
  • Interdisciplinary Team Reports: Review inputs from the interdisciplinary team that may address the resident’s cognitive function and orientation.

2. Understanding Definitions

• Recall in Nursing Home: This refers to the resident's ability to accurately recall that they are currently residing in a nursing home. This is part of assessing the resident’s overall orientation and cognitive function.

3. Coding Instructions

• Code C0900D:
  • 0: No, the resident does not recall that they are in a nursing home.
  • 1: Yes, the resident recalls that they are in a nursing home.
• Example: If a resident consistently answers correctly when asked where they are living, code C0900D as '1'.

4. Coding Tips

• Standardized Questions: Use a consistent set of questions to assess the resident's recall of being in a nursing home.
• Context of Assessment: Ensure the assessment is done in a calm and quiet environment to minimize distractions that could affect the resident's response.

5. Documentation

• Required Documentation:
  • Interview Notes: Document the resident’s responses during the mental status interview.
  • Observation Records: Include observations of the resident’s orientation during daily interactions.
  • Care Plan Updates: Record any changes in cognitive status and related interventions in the care plan.
• Example: "On 05/10/2024, during the mental status assessment, the resident correctly recalled that they are living in a nursing home. This response was consistent with previous assessments."

6. Common Errors to Avoid

• Misinterpretation: Misinterpreting a resident’s confusion or disorientation as a permanent state without confirming through multiple assessments.
• Inconsistent Documentation: Failing to document each assessment thoroughly, leading to inconsistencies in the resident's cognitive status records.
• Overlooking Context: Not considering temporary factors that might affect the resident's recall ability, such as recent medication changes or acute illnesses.

7. Practical Application

• Scenario: A resident is interviewed as part of their quarterly assessment. The staff asks, "Do you know where you are right now?" The resident responds, "Yes, I am in the nursing home." This response is documented, and it aligns with previous assessments indicating the resident is oriented to their location. Therefore, C0900D is coded as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set C0900D 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.