D0500D2: PHQ-9 Staff Assessment - Feeling Tired-Little Energy-Frequency, Step-by-Step

Step-by-Step Coding Guide for Item Set D0500D2: PHQ-9 Staff Assessment - Feeling Tired/Little Energy (Frequency)

1. Review of Medical Records

• Objective: Begin by examining the resident’s recent health records, nursing notes, and previous assessments within the 7-day look-back period to identify documented instances where the resident appeared tired or showed low energy levels.
• Procedure:
  • Review nurse and physician notes, shift reports, and any clinical observations related to fatigue or lethargy.
  • Check for any medical diagnoses or conditions in Section I that could contribute to fatigue, such as chronic illnesses or recent changes in medication.

2. Understanding Definitions

• Feeling Tired/Little Energy: For the purposes of Item D0500D2, this refers to noticeable episodes where the resident appears unusually fatigued, lacks vitality, or expresses feeling “tired” or “low energy” during interactions.
• Frequency Coding: This is coded based on the frequency with which the resident experiences or expresses feeling tired. Assessors should consider observable episodes or staff-reported behaviors of fatigue.

3. Coding Instructions

• Code Options:
  • 0 - Not exhibited: No instances of feeling tired or low energy were noted during the look-back period.
  • 1 - 1 to 2 days: Resident exhibited signs of tiredness or low energy on 1 or 2 days within the look-back period.
  • 2 - 3 to 4 days: Signs of tiredness or low energy observed on 3 to 4 days.
  • 3 - 5 to 6 days: Resident exhibited tiredness or low energy on 5 to 6 days.
  • 4 - Daily: Resident showed tiredness or low energy every day within the 7-day period.
• Procedure:
  • Conduct interviews with staff from all shifts who may have observed the resident.
  • Observe the resident directly, if possible, to assess their energy levels during activities.

4. Coding Tips

• Consistency: Ensure consistency by checking with multiple staff members to verify the frequency of tiredness.
• Documentation Correlation: Ensure any coded responses are supported by notes in the medical record. For example, if “Daily” is coded, daily instances of tiredness should be observed in progress notes.
• Resident-Reported Data: If the resident is unable to report directly, rely on observed behaviors or reports from staff familiar with the resident’s daily energy levels.

5. Documentation

• Objective: All coding should be supported by clear and consistent documentation to ensure accuracy and compliance.
• Documentation Tips:
  • Include specific phrases used by the resident or direct observations, such as “appeared fatigued” or “had difficulty staying awake during meals.”
  • Ensure that each instance of fatigue or low energy is logged in the progress notes, including the context (e.g., after meals, during morning routines).
• Cross-Referencing: If fatigue is noted in another section (e.g., Section E for behavioral symptoms), ensure that this documentation supports the coding for D0500D2.

6. Common Errors to Avoid

• Overlooking Non-Reported Instances: Relying only on self-reported data or a single source can lead to undercoding. Make sure to include observations and input from all relevant staff.
• Incorrect Look-Back Period: Only code instances of tiredness or low energy that occurred within the 7-day look-back period.
• Inconsistent Documentation: Avoid coding without corresponding documentation in the medical record, which is necessary for compliance and audit purposes.

7. Practical Application

• Scenario Example:
  • Resident A exhibited signs of low energy on 3 days and specifically mentioned feeling tired during morning care on 2 additional days.
  • Coding: Code as 3 (5 to 6 days) since resident consistently showed fatigue over multiple days.
  • Documentation: Ensure these observations are clearly noted in the shift reports, with staff remarks indicating fatigue levels.

Please note that the information provided in this guide for MDS 3.0 Item set D0500D2 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.