Step-by-Step Coding Guide for Item Set D0500B2: PHQ Staff: Feeling Down, Depressed - Frequency

1. Review of Medical Records

• Objective: Gather comprehensive information on the resident’s mental health, particularly regarding feelings of being down or depressed.
• Steps:
  1. Obtain Records: Collect the resident’s full medical history, including psychological assessments, nursing notes, and progress notes.
  2. Review Historical Data: Identify any previous diagnoses or treatments for depression.
  3. Recent Documentation: Focus on the latest notes to find references to the resident feeling down or depressed.

2. Understanding Definitions

• Feeling Down, Depressed: This refers to experiencing sadness, low mood, or symptoms of depression.
• Frequency Assessment (D0500B2): This is part of the PHQ (Patient Health Questionnaire) staff assessment to determine how often the resident feels down or depressed.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set D0500B2 on the MDS form.
  2. Interview Staff: Conduct interviews with staff members who interact with the resident to gather insights on the frequency of depressive feelings.
  3. Cross-Reference Documentation: Verify staff observations with nursing notes and other documentation.
  4. Code Based on Frequency:
     • Code 0: Never or 1 day
     • Code 1: 2-6 days (Less than half the days)
     • Code 2: 7-11 days (Half or more of the days)
     • Code 3: 12-14 days (Nearly every day)
  5. Verify Accuracy: Ensure the coding is consistent with the staff’s observations and the documentation.

4. Coding Tips

• Consistent Terminology: Ensure all staff use the same terms for “down” or “depressed.”
• Regular Updates: Frequently update records to capture any changes in the resident’s mood.
• Thorough Documentation: Ensure all observations and reports are well-documented to maintain accuracy.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set D0500B2 indicating the frequency of feeling down or depressed.
  • Medical Records: Detailed notes on the resident’s mood from psychological evaluations and daily logs.
  • Verification Notes: Notes from staff interviews confirming the resident's mood and frequency of depressive feelings.

6. Common Errors to Avoid

• Assumptions: Avoid making assumptions based on past history without current verification.
• Incomplete Information: Ensure all relevant records and staff inputs are reviewed for comprehensive assessment.
• Inconsistent Entries: Avoid discrepancies between staff reports and documented observations.

7. Practical Application

• Example:
  • Resident Background: Ms. Jane Smith, a resident with a history of depressive episodes.
  • Review Process: Access Ms. Smith’s medical records, including recent psychological evaluations and nursing notes.
  • Staff Interviews: Conduct interviews with nursing staff and caregivers to gather insights on Ms. Smith’s mood.
  • Coding Process:
    • Step 1: Locate item set D0500B2 on the MDS form.
    • Step 2: Interview reveals that Ms. Smith feels down or depressed “half or more of the days.”
    • Step 3: Verify with recent nursing notes and staff observations.
    • Step 4: Enter 2 indicating that Ms. Smith feels down or depressed “half or more of the days.”
  • Illustration:
    • Provide a sample MDS form showing item set D0500B2 with “2” entered.
    • Include an example of a nursing note confirming the observation.

Please note that the information provided in this guide for MDS 3.0 Item set D0500B2 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.