Step-by-Step Coding Guide for Item Set D0500H1: PHQ Staff - Slow, Fidgety, Restless - Presence

1. Review of Medical Records

• Objective: Accurately determine and document whether the resident has exhibited behaviors such as moving slowly, being fidgety, or feeling restless as observed by staff.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, behavioral health records, physician assessments, and previous psychiatric evaluations.
  2. Identify Documentation of Behaviors: Look for documented instances where staff have noted the resident moving slowly, being fidgety, or feeling restless.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Slow, Fidgety, Restless: These terms describe different types of motor activity and agitation observed in residents.
  • Slow: Reduced speed of movement or response.
  • Fidgety: Small, repetitive movements that indicate restlessness or agitation.
  • Restless: Inability to stay still, often accompanied by a need to move frequently.
• Presence: Indicates whether these behaviors have been observed by staff.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if the resident has exhibited behaviors such as moving slowly, being fidgety, or feeling restless.
  2. Verify Documentation: Ensure that these behaviors are clearly noted in the records, including the context and frequency of the observations.
  3. Code Appropriately: Enter the appropriate code for the resident’s observed behaviors in item set D0500H1:
     • 0: No, the resident did not exhibit these behaviors.
     • 1: Yes, the resident exhibited these behaviors.

4. Coding Tips

• Accurate Identification: Ensure the behaviors are correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding these behaviors.
• Consultation: If there is any uncertainty regarding the presence of these behaviors, consult with the interdisciplinary team or staff members who have directly observed the resident.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes from nursing staff documenting observations of the resident’s motor activity and behavior.
  • Behavioral Health Records: Records from behavioral health professionals detailing any observations or assessments of the resident’s behavior.
  • Physician Assessments: Assessments from physicians noting any observed behaviors or agitation.
  • Previous Psychiatric Evaluations: Any previous psychiatric evaluations that have documented these behaviors.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the observed behaviors through multiple records and notes.
• Incomplete Documentation: Make sure all relevant nursing notes, behavioral health records, and physician assessments are included to support the behaviors documented.
• Assumptions: Do not assume the resident’s behaviors without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Sarah, a 72-year-old resident, has been observed by staff to exhibit fidgety and restless behaviors.
  • Steps:
    1. Review Records: The nurse reviews Sarah’s medical records, noting the nursing notes and behavioral health records documenting Sarah’s fidgety and restless behaviors.
    2. Identify Behaviors: It is confirmed through the documentation that Sarah has exhibited these behaviors as observed by staff.
    3. Document and Code: The nurse documents Sarah’s behaviors in her records and codes D0500H1 as "1".
  • Outcome: Sarah’s fidgety and restless behaviors 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 D0500H1 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.