C1310A: Acute Onset Mental Status Change, Step-by-Step
Step-by-Step Coding Guide for Item Set C1310A: Acute Onset Mental Status Change
1. Review of Medical Records
- Objective: Identify and document any acute onset of mental status change in the resident.
- Steps:
- Collect Relevant Documentation: Gather medical records, nursing notes, and incident reports.
- Identify Changes: Look for documentation indicating sudden changes in mental status.
- Consult with Healthcare Providers: Verify with attending healthcare providers and staff about any noted acute changes in mental status.
2. Understanding Definitions
- Acute Onset: A sudden and noticeable change in the resident's mental status, which is a departure from their baseline cognitive function.
- Mental Status Change: This may include confusion, disorientation, altered level of consciousness, or significant behavioral changes.
3. Coding Instructions
- Steps:
- Review Records: Confirm the documentation of an acute onset mental status change.
- Determine Timing: Ensure that the change occurred acutely, rather than gradually over time.
- Select Appropriate Code: Code the presence of acute onset mental status change in item C1310A of the MDS.
- Accurate Entry: Ensure that the information is correctly entered into the MDS with all relevant details.
4. Coding Tips
- Consistency: Ensure consistency across all documentation regarding the acute onset of mental status change.
- Detailed Notes: Include specific observations and descriptions of the mental status change.
- Collaboration: Work closely with the interdisciplinary team to ensure accurate and thorough documentation.
5. Documentation
- Required:
- Incident Reports: Any reports that document the acute onset of mental status changes.
- Nursing Notes: Detailed nursing notes that describe the change in mental status and any interventions.
- Physician Documentation: Notes from physicians that detail the diagnosis and observations of mental status change.
- Care Plans: Updates to the resident’s care plan to reflect the change and any interventions or treatments.
6. Common Errors to Avoid
- Misidentifying Onset: Ensure the change is acute and not a gradual decline or chronic condition.
- Incomplete Documentation: Avoid missing critical details in documentation that describe the onset and nature of the mental status change.
- Lack of Verification: Confirm the change with multiple sources and document accordingly to avoid misclassification.
7. Practical Application
- Example:
- Resident Profile: Jane Doe, an 85-year-old female, previously oriented and alert, suddenly becomes confused and disoriented.
- Steps:
- Review Records: Gather nursing notes, physician documentation, and incident reports.
- Identify Change: Note the documented sudden confusion and disorientation.
- Consult Providers: Verify with the attending nurse and physician about the acute change.
- Enter Code: Document the acute onset mental status change under item C1310A in the MDS.
- Documentation: Ensure all records reflect the sudden change, including detailed observations and any interventions.
Please note that the information provided in this guide for MDS 3.0 Item set C1310A 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.
