Step-by-Step Coding Guide for Item Set C0900Z: Staff Assessment Mental Status: None of Above Recalled

1. Review of Medical Records

• Objective: Identify instances where the resident could not recall any of the items assessed in the mental status evaluation.
• Steps:
  1. Gather Documentation: Collect the resident’s medical records, previous mental status assessments, and any relevant nursing notes.
  2. Check Previous Assessments: Look at past mental status assessments to compare the resident's recall abilities.
  3. Consult Staff: Discuss with nurses, aides, and other staff members who interact regularly with the resident to get a comprehensive understanding of the resident's recall abilities.

2. Understanding Definitions

• Mental Status Assessment: A systematic evaluation to determine the resident’s cognitive functions, including memory, orientation, attention, and recall abilities.
• None of Above Recalled: Indicates that the resident could not recall any of the items asked during the assessment.

3. Coding Instructions

• Steps:
  1. Conduct Assessment: Ensure the staff conducts a thorough mental status assessment following standard protocols.
  2. Document Recall Ability: Note the resident’s ability to recall the items asked during the assessment.
  3. Record Findings: If the resident is unable to recall any items, code this under item C0900Z.
  4. Accurate Entry: Enter the data accurately into the MDS system, ensuring all relevant details are captured.

4. Coding Tips

• Consistency: Ensure consistency in documentation across all staff assessments.
• Clear Criteria: Use clear and consistent criteria for evaluating the resident's recall ability.
• Interdisciplinary Approach: Collaborate with the interdisciplinary team to ensure all observations are accurately recorded.

5. Documentation

• Required:
  • Mental Status Assessment Forms: Document the specific questions asked and the resident's responses.
  • Nursing Notes: Include detailed notes on the resident’s cognitive abilities and any observed changes.
  • Staff Observations: Document observations from staff who interact with the resident regularly.
  • Care Plans: Update the resident’s care plan to reflect findings from the mental status assessment.

6. Common Errors to Avoid

• Incomplete Assessments: Ensure the mental status assessment is comprehensive and covers all required items.
• Inconsistent Documentation: Avoid discrepancies between different staff members’ observations.
• Overlooking Details: Document all relevant details accurately to ensure a thorough assessment.

7. Practical Application

• Example:
  • Resident Profile: John Smith, a 78-year-old male, recently admitted to the facility.
  • Steps:
    1. Review Records: Collect John’s medical history and previous assessments.
    2. Conduct Assessment: Staff conducts a mental status assessment, asking John to recall specific items.
    3. Document Responses: Note that John was unable to recall any of the items asked.
    4. Enter Code: Code the inability to recall any items under item C0900Z in the MDS.
    5. Update Documentation: Ensure all documentation reflects John’s recall abilities, including nursing notes and care plans.

Please note that the information provided in this guide for MDS 3.0 Item set C0900Z 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.