Step-by-Step Coding Guide for Item Set D0500F1: PHQ Staff: Feeling Bad About Self - Presence

1. Review of Medical Records

• Objective: Ensure accurate coding by thoroughly reviewing the resident’s medical records.
• Steps:
  1. Gather Records: Collect all relevant documentation, including nursing notes, physician assessments, and psychiatric evaluations.
  2. Identify Symptoms: Look for documented instances where the resident expressed feelings of worthlessness or inadequacy.
  3. Verify Consistency: Ensure the symptoms are consistently noted across different records and align with the assessment period.

2. Understanding Definitions

• Feeling Bad About Self: Refers to feelings of worthlessness, excessive guilt, or self-blame that can be a sign of depression.
• PHQ-9: A standardized tool used to assess depression severity, where this item is a part of the questionnaire.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set D0500F1 on the MDS form.
  2. Determine Presence:
     • Review the collected medical records to identify documented instances of the resident feeling bad about themselves.
     • Confirm that these instances occurred during the assessment period.
  3. Code the Item:
     • Response Format: Use the following codes to indicate the presence of feelings of worthlessness or excessive guilt:
       • 0: Behavior not present
       • 1: Behavior present
     • Input the appropriate code in the designated field for item set D0500F1.
  4. Complete Entry: Ensure the correct code is recorded and verify accuracy.

4. Coding Tips

• Accurate Documentation: Double-check nursing notes and physician assessments to ensure all instances of feeling bad about oneself are captured.
• Consistent Language: Use consistent language when documenting and coding this item to avoid confusion.
• Assessment Period: Only include instances observed during the specified assessment period.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set D0500F1 indicating the presence or absence of feelings of worthlessness.
  • Nursing Notes: Detailed notes documenting instances where the resident expressed feeling bad about themselves, including date, time, and context.
  • Physician Assessments: Assessments confirming these feelings and any related diagnoses or observations.
  • Psychiatric Evaluations: Documentation from psychiatric evaluations if available, providing additional insights.

6. Common Errors to Avoid

• Inconsistent Documentation: Ensure that instances of feeling bad about oneself are consistently documented across all records.
• Misidentification: Be careful not to confuse feelings of worthlessness with other emotional issues like anxiety or temporary sadness.
• Outside Assessment Period: Do not include symptoms that occurred outside the designated assessment period.

7. Practical Application

• Example:
  • Resident Background: Mr. John Doe has exhibited signs of feeling bad about himself, expressing guilt and worthlessness.
  • Review Process: Access Mr. Doe’s nursing notes, physician assessments, and psychiatric evaluations.
  • Verification: Confirm instances of feeling bad about himself, ensuring these instances occurred during the assessment period.
  • Coding Process:
    • Step 1: Locate item set D0500F1 on the MDS form.
    • Step 2: Verify and classify the presence of feeling bad about oneself.
    • Step 3: Enter the appropriate code (e.g., "1" for presence) in the field for item set D0500F1.
    • Step 4: Ensure all records and documentation are complete and consistent.
  • Illustration:
    • Provide a sample MDS form showing item set D0500F1 with the appropriate code entered.
    • Include an example of nursing notes documenting feelings of worthlessness, with dates and descriptions.

Please note that the information provided in this guide for MDS 3.0 Item set D0500F1 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.