Step-by-Step Coding Guide for Item Set D0500B1: PHQ Staff - Feeling Down, Depressed - Presence

1. Review of Medical Records

• Objective: Accurately determine and document the presence of feelings of being down or depressed in the resident, as assessed by staff using the PHQ (Patient Health Questionnaire).
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, nursing notes, psychological evaluations, and previous assessments.
  2. Identify Documentation of Depression: Look for documented instances where the resident has expressed or exhibited signs of feeling down or depressed.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Feeling Down, Depressed: Refers to a state of low mood and aversion to activity, which can affect a person's thoughts, behavior, feelings, and sense of well-being.
• PHQ Staff Assessment: A screening tool used by healthcare staff to identify and evaluate the presence and severity of depression in residents.
• Key Points:
  • Presence: Indicates whether the resident has exhibited or reported feelings of being down or depressed.
  • Assessment Period: Typically refers to the observation period covered by the assessment (e.g., the last two weeks).

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if the resident has exhibited or reported feelings of being down or depressed.
  2. Verify Documentation: Ensure that the presence of these feelings is clearly noted in the records, including details of the assessment by staff.
  3. Code Appropriately: Enter the code for the presence of feeling down or depressed in item set D0500B1:
     • 1: Yes, the resident has exhibited or reported feelings of being down or depressed.
     • 0: No, the resident has not exhibited or reported feelings of being down or depressed.

4. Coding Tips

• Accurate Identification: Ensure the presence of feeling down or depressed is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s feelings of depression.
• Clarify with the Resident: If there is any uncertainty, clarify with the resident or their legal representative to ensure accurate coding.

5. Documentation

• Required:
  • PHQ Assessment: Completed PHQ forms documenting the resident’s responses and the staff’s observations.
  • Nursing Notes: Detailed notes from nursing staff documenting observations and interactions with the resident.
  • Physician Notes: Notes from physicians detailing the diagnosis and any reports of depression.
  • Psychological Evaluations: Evaluations from psychologists or psychiatrists detailing the assessment and diagnosis of depression.
  • Care Plans: Comprehensive care plans that outline interventions and support for the resident’s emotional and psychological well-being.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the presence of feelings of being down or depressed through multiple records and notes.
• Incomplete Documentation: Make sure all relevant PHQ assessments, nursing notes, and psychological evaluations are included to support the presence of depression.
• Assumptions: Do not assume the resident feels down or depressed without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Sarah, an 82-year-old resident, has been reported by nursing staff to exhibit signs of feeling down and depressed.
  • Steps:
    1. Review Records: The nurse reviews Sarah’s medical records, noting the completed PHQ assessments and nursing notes documenting Sarah’s feelings of depression.
    2. Identify Presence: It is confirmed through the documentation that Sarah has exhibited signs of feeling down and depressed.
    3. Document and Code: The nurse documents the presence of these feelings in Sarah’s records and codes D0500B1 as "1".
  • Outcome: Sarah’s feelings of being down or depressed 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 D0500B1 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.