Step-by-Step Coding Guide for Item Set D0150H2: PHQ Resident - Slow, Fidgety, Restless - Frequency

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s behaviors of being slow, fidgety, or restless.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, behavior logs, physician notes, and previous assessments.
  2. Identify Documentation of Behaviors: Look for documented instances of the resident exhibiting slow movements, fidgetiness, or restlessness.
  3. Confirm Details: Verify the consistency and accuracy of the documentation through various sources within the medical records.

2. Understanding Definitions

• Slow, Fidgety, Restless: Behaviors characterized by the resident moving slowly, exhibiting restless movements, or showing signs of fidgetiness. These behaviors can indicate underlying anxiety, discomfort, or other psychological conditions.
• Frequency: The number of days these behaviors were observed during the assessment period.
  • 0: Never or 1 day
  • 1: 2-6 days (less than half the days)
  • 2: 7-11 days (half or more of the days)
  • 3: 12-14 days (nearly every day)

3. Coding Instructions

• Steps:
  1. Observe Resident: During the assessment period, observe the resident for any signs of slow movements, fidgetiness, or restlessness.
  2. Evaluate Documentation: Review medical records to ensure that observations of these behaviors are accurately documented.
  3. Code Appropriately: Use the following scale to code the resident’s behaviors based on the frequency they were observed:
     • 0: Never or 1 day
     • 1: 2-6 days
     • 2: 7-11 days
     • 3: 12-14 days

4. Coding Tips

• Accurate Observation: Ensure that staff are trained to accurately observe and document behaviors of being slow, fidgety, or restless.
• Clarify Definitions: Make sure the staff understands what constitutes slow movements, fidgetiness, and restlessness.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s behaviors.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes from nursing staff documenting the resident’s behaviors during the assessment period.
  • Behavior Logs: Regular entries detailing the frequency and intensity of the resident’s slow movements, fidgetiness, or restlessness.
  • Physician Notes: Documentation from physicians regarding assessments and treatments related to the resident’s behaviors.
  • Care Plans: Include information about the resident’s behavior management plan and any interventions used.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the frequency and context of the behaviors through multiple records and observations.
• Incomplete Documentation: Make sure all relevant notes and logs are included.
• Assumptions: Do not assume the frequency of behaviors without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Sarah, a 75-year-old resident, exhibits restlessness and fidgetiness, especially in the afternoons.
  • Steps:
    1. Observe Resident: The nurse observes Sarah over a two-week period and notes that Sarah is restless and fidgety on most days.
    2. Evaluate Documentation: The nurse reviews Sarah’s medical records, confirming that these behaviors have been documented consistently over the assessment period.
    3. Document and Code: The nurse documents Sarah’s behaviors in her records and codes D0150H2 as "2" (7-11 days).
  • Outcome: Sarah’s behaviors of being slow, fidgety, or restless are accurately documented and coded, ensuring proper follow-up and behavior management.

Please note that the information provided in this guide for MDS 3.0 Item set D0150H2 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.