Step-by-Step Coding Guide for Item Set D0150D1: PHQ Resident: Feeling Tired/Little Energy - Presence

1. Review of Medical Records

• Objective: Collect all necessary information about the resident’s feelings of tiredness or low energy.
• Steps:
  1. Gather Medical Records: Obtain all relevant medical records, including recent assessments, progress notes, and resident interviews.
  2. Identify Documentation: Look for documentation indicating the presence of tiredness or low energy.
  3. Verify Consistency: Ensure that the presence of these symptoms is consistently documented across all sources.

2. Understanding Definitions

• Feeling Tired/Little Energy: This refers to the resident’s self-reported experience of fatigue or low energy, which can affect their daily activities and overall well-being.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set D0150D1 on the MDS form.
  2. Confirm Presence: Verify the presence of feelings of tiredness or low energy based on the resident’s self-report and documented evidence.
  3. Code the Item:
     • 0: No, if the resident does not report feeling tired or having little energy.
     • 1: Yes, if the resident reports feeling tired or having little energy.
  4. Complete Entry: Double-check the entry for accuracy and completeness.

4. Coding Tips

• Accurate Documentation: Ensure that the resident’s feelings of tiredness or low energy are clearly documented with detailed notes.
• Consistency: Confirm that the documentation is consistent across all records and sources.
• Resident Interview: Conduct a thorough interview with the resident to capture their self-reported symptoms accurately.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set D0150D1 indicating whether the resident reports feeling tired or having little energy.
  • Resident Interviews: Detailed notes from interviews with the resident.
  • Progress Notes: Documentation from healthcare providers noting the resident’s reported symptoms.
  • Assessment Records: Any relevant assessments that include the resident’s self-reported feelings of tiredness or low energy.

6. Common Errors to Avoid

• Incomplete Documentation: Avoid coding this item if there is no clear and consistent documentation of the resident’s feelings of tiredness or low energy.
• Inconsistent Records: Ensure all documentation sources consistently reflect the resident’s self-reported symptoms.
• Assumptions: Do not code based on assumptions or incomplete information; always rely on documented evidence and direct resident reports.

7. Practical Application

• Example:
  • Resident Background: Ms. Jane Doe reports feeling tired and having little energy during her recent assessment.
  • Review Process: Access Ms. Doe’s medical records, including recent assessments, progress notes, and interview documentation.
  • Verification: Confirm the presence of these symptoms through multiple documented sources.
  • Coding Process:
    • Step 1: Locate item set D0150D1 on the MDS form.
    • Step 2: Confirm the documentation of feelings of tiredness or low energy.
    • Step 3: Enter the code “1” for yes if these symptoms are documented as present.
    • Step 4: Verify the entry with the documentation.
  • Illustration:
    • Provide a sample MDS form showing item set D0150D1 with the correct code entered.
    • Include an example of a resident interview noting the resident’s report of feeling tired or having little energy.

Please note that the information provided in this guide for MDS 3.0 Item set D0150D1 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.