Step-by-Step Coding Guide for Item Set C1310B: Signs of Delirium - Inattention

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s signs of inattention as a symptom of delirium.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, nursing notes, behavioral health reports, and previous assessments.
  2. Identify Inattention Documentation: Look for documented instances of inattention, such as difficulty focusing, easily distracted behavior, or trouble maintaining a coherent line of thought.
  3. Confirm Details: Verify the consistency and accuracy of the inattention documentation through various sources within the medical records.

2. Understanding Definitions

• Inattention: A state in which the resident has difficulty focusing attention, is easily distracted, or has trouble following conversations or instructions. This is a key symptom of delirium.
• Signs of Delirium: Behavioral changes that include altered consciousness, disorganized thinking, and inattention, typically developing over a short period of time.

3. Coding Instructions

• Steps:
  1. Observe and Document: During the assessment period, observe the resident’s behavior for signs of inattention.
  2. Evaluate Inattention: Determine if the resident shows signs of inattention, such as difficulty focusing, easily distracted behavior, or trouble maintaining a coherent line of thought.
  3. Code Appropriately: Use the following scale to code the resident’s inattention:
     • 0: Behavior not exhibited
     • 1: Behavior of this type occurred 1 to 2 days
     • 2: Behavior of this type occurred 3 to 4 days
     • 3: Behavior of this type occurred 5 to 7 days

4. Coding Tips

• Accurate Observation: Ensure that the assessment is conducted in a consistent and controlled environment to accurately observe the resident’s behavior.
• Clarify Definitions: Make sure the staff understands the definitions and examples of inattention as a sign of delirium.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s inattention.

5. Documentation

• Required:
  • Observation Notes: Document the observations made during the assessment, including specific instances of the resident exhibiting signs of inattention.
  • Staff Reports: Include reports from staff members detailing their observations and interactions with the resident regarding signs of inattention.
  • Assessment Summary: Summarize the resident’s behavioral signs in the assessment records, highlighting instances of inattention.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s behavior through multiple observations.
• Incomplete Documentation: Make sure all relevant details about the resident’s signs of inattention are thoroughly documented.
• Assumptions: Do not assume the presence or absence of inattention without proper documentation and observation.

7. Practical Application

• Example:
  • Resident Profile: Alice, an 85-year-old resident, is being assessed for signs of delirium, particularly inattention.
  • Steps:
    1. Observe Behavior: The nurse observes Alice during the assessment period and notes several instances where Alice is easily distracted and has trouble following conversations.
    2. Determine Frequency: Alice exhibits signs of inattention on 3 to 4 days within the assessment period.
    3. Document and Code: The nurse documents Alice’s behavior in her records and codes C1310B as "2".
  • Outcome: Alice’s signs of inattention are 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 C1310B 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.