D0150H1: PHQ Resident - Slow, Fidgety, Restless - Presence, Step-by-Step

Step-by-Step Coding Guide for Item Set D0150H1: PHQ Resident - Slow, Fidgety, Restless - Presence

1. Review of Medical Records

The first step in coding for item D0150H1 involves a thorough review of the resident’s medical records. This includes:

• Physician’s Notes: Examine progress notes, history, and physical examination records.
• Nursing Notes: Check nursing notes for observations and documentation of the resident’s activity level.
• Behavioral Health Records: Review any psychological or psychiatric evaluations and treatment notes.
• Interdisciplinary Notes: Check notes from all members of the care team, including social workers and therapists.

2. Understanding Definitions

Understanding the key definitions related to this item is crucial:

• Slow, Fidgety, Restless: These terms refer to changes in the resident’s motor activity. Being noticeably slow in movement or speech, or alternatively, being excessively fidgety or restless, moving around more than usual.
• PHQ-9 (Patient Health Questionnaire-9): A standardized tool used to assess depressive symptoms, including psychomotor changes such as being slowed down or fidgety .

3. Coding Instructions

Follow these steps for accurate coding:

1. Ask the Resident: Conduct the PHQ-9 interview, asking the resident if they have been bothered by moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that they have been moving around a lot more than usual, over the past two weeks.
2. Determine Symptom Presence:
   • Code 0 (No): If the resident indicates that the symptoms are not present.
   • Code 1 (Yes): If the resident indicates that the symptoms are present.
   • Code 9 (No Response): If the resident was unable or chose not to complete the assessment or responded nonsensically.
3. Assess Symptom Frequency: If the resident indicates that the symptoms are present, determine how often they have been bothered by this symptom in the past two weeks:
   • Code 0: Never or 1 day.
   • Code 1: 2-6 days (several days).
   • Code 2: 7-11 days (half or more of the days).
   • Code 3: 12-14 days (nearly every day) .

4. Coding Tips

• Specific Documentation: Ensure that the resident’s responses are documented verbatim to capture their experience accurately.
• Neutral Probing: If the resident is unsure, gently probe with neutral questions to help them clarify their responses.
• Consistency: Verify that the resident’s responses are consistent with other documented observations in their medical record.

5. Documentation

Accurate documentation is critical for compliance and effective care planning:

• Daily Records: Maintain thorough daily records of the resident’s motor activity and any changes.
• Care Plans: Update care plans to reflect the presence of psychomotor changes and corresponding interventions.
• Interdisciplinary Communication: Ensure all team members are informed of and document any psychomotor changes and their impact on the resident’s functioning.

6. Common Errors to Avoid

• Inconsistent Documentation: Avoid discrepancies between the MDS data and other medical records.
• Incomplete Assessments: Ensure all parts of the PHQ-9 are completed unless the resident is unable or unwilling to participate.
• Incorrect Coding: Double-check coding entries for accuracy, especially the presence and frequency columns.

7. Practical Application

Use case studies and scenarios to apply your knowledge:

• Example 1: A resident reports feeling extremely restless and moving around more than usual nearly every day for the past two weeks.
  • Coding: D0150H1 (Symptom Presence) would be coded 1 (Yes), and D0150H2 (Symptom Frequency) would be coded 3 (12-14 days).
  • Rationale: The resident indicates frequent restlessness and increased movement nearly every day .
• Example 2: A resident indicates they have felt noticeably slowed down in their movements for several days over the past two weeks.
  • Coding: D0150H1 (Symptom Presence) would be coded 1 (Yes), and D0150H2 (Symptom Frequency) would be coded 1 (2-6 days).
  • Rationale: The resident reports being slowed down in movement for several days .

Please note that the information provided in this guide for MDS 3.0 Item set D0150H1 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.