Step-by-Step Coding Guide for Item Set C1310C: Signs of Delirium: Disorganized Thinking

1. Review of Medical Records

• Objective: To ensure accurate coding, start by thoroughly reviewing the resident’s medical records.
• Steps:
  1. Collect Documentation: Gather all relevant records, including nursing notes, physician assessments, and behavioral logs.
  2. Identify Symptoms: Look for documented instances of disorganized thinking, confusion, or inability to follow a logical thought process.
  3. Verify Consistency: Ensure the symptoms are consistently noted across different records and align with the assessment period.

2. Understanding Definitions

• Disorganized Thinking: Characterized by confusion, difficulty in following a logical sequence of thoughts, or impaired reasoning that can lead to inconsistent or illogical speech and actions.
• Signs of Delirium: Acute changes in mental status, including disorganized thinking, inattention, and altered levels of consciousness.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set C1310C on the MDS form.
  2. Determine Presence:
     • Review the collected medical records to identify documented instances of disorganized thinking.
     • Confirm that these instances occurred during the assessment period.
  3. Code the Item:
     • Response Format: Use the following codes to indicate the presence of disorganized thinking:
       • 0: Behavior not present
       • 1: Behavior continuously present, does not fluctuate
       • 2: Behavior present, fluctuates
     • Input the appropriate code in the designated field for item set C1310C.
  4. Complete Entry: Ensure the correct code is recorded and verify accuracy.

4. Coding Tips

• Accurate Documentation: Double-check nursing notes and physician assessments to ensure all instances of disorganized thinking are captured.
• Fluctuating Behavior: Pay special attention to whether the behavior is continuous or fluctuating, as this affects the coding.
• Assessment Period: Only include instances of disorganized thinking observed during the specified assessment period.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set C1310C indicating the presence and nature of disorganized thinking.
  • Nursing Notes: Detailed notes documenting instances of disorganized thinking, including date, time, and context.
  • Physician Assessments: Assessments confirming disorganized thinking and any related diagnoses or observations.
  • Behavioral Logs: Logs tracking changes in behavior, highlighting periods of disorganized thinking.

6. Common Errors to Avoid

• Inconsistent Documentation: Ensure that instances of disorganized thinking are consistently documented across all records.
• Misidentification: Be careful not to confuse disorganized thinking with other cognitive issues such as dementia or anxiety.
• Outside Assessment Period: Do not include symptoms that occurred outside the designated assessment period.

7. Practical Application

• Example:
  • Resident Background: Mrs. Jane Doe has exhibited signs of disorganized thinking, including confusion and illogical speech, during her stay.
  • Review Process: Access Mrs. Doe’s nursing notes, physician assessments, and behavioral logs.
  • Verification: Confirm instances of disorganized thinking, noting whether the behavior is continuous or fluctuates.
  • Coding Process:
    • Step 1: Locate item set C1310C on the MDS form.
    • Step 2: Verify and classify the disorganized thinking as either continuous or fluctuating.
    • Step 3: Enter the appropriate code (e.g., "2" for fluctuating behavior) in the field for item set C1310C.
    • Step 4: Ensure all records and documentation are complete and consistent.
  • Illustration:
    • Provide a sample MDS form showing item set C1310C with the appropriate code entered.
    • Include an example of nursing notes documenting disorganized thinking, with dates and descriptions.

Please note that the information provided in this guide for MDS 3.0 Item set C1310C 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.