Step-by-Step Coding Guide for Item Set D0500H2: PHQ Staff - Slow, Fidgety, Restless - Frequency

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s behavior of being slow, fidgety, or restless and its frequency.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, behavioral health reports, and previous assessments.
  2. Identify Relevant Behaviors: Look for documented instances where the resident has exhibited behaviors of being slow, fidgety, or restless.
  3. Confirm Details: Verify the consistency of these behaviors through various sources within the medical records.

2. Understanding Definitions

• Slow, Fidgety, Restless: Refers to observable behaviors where the resident appears to be moving slowly, frequently fidgeting, or showing signs of restlessness.
• Frequency: The regularity with which these behaviors occur, typically measured over the past two weeks.

3. Coding Instructions

• Steps:
  1. Observe Behavior: During the assessment period, observe and document the resident’s behavior of being slow, fidgety, or restless.
  2. Determine Frequency: Identify the frequency with which the resident exhibits these behaviors using the following scale:
     • 0: Never or 1 day
     • 1: 2-6 days (Several days)
     • 2: 7-11 days (More than half the days)
     • 3: 12-14 days (Nearly every day)
  3. Code Appropriately: Enter the corresponding code in item set D0500H2 based on the observed frequency of the behaviors.

4. Coding Tips

• Accurate Observation: Ensure that the assessment is conducted in a consistent and controlled environment to accurately observe the resident’s behaviors.
• Clarify Definitions: Make sure the staff understands the definitions of frequency categories (e.g., Never, Several days).
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s behavior.

5. Documentation

• Required:
  • Observation Notes: Document the observations made during the assessment, including specific instances of the resident exhibiting slow, fidgety, or restless behaviors.
  • Staff Reports: Include reports from staff members detailing their observations and interactions with the resident.
  • Assessment Summary: Summarize the resident’s behavior in the assessment records, including the frequency of observed behaviors.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s behavior through multiple observations.
• Incomplete Documentation: Make sure all relevant details about the resident’s behavior are thoroughly documented.
• Assumptions: Do not assume the resident’s behavior without proper documentation and observation.

7. Practical Application

• Example:
  • Resident Profile: Mary, an 85-year-old resident, is being assessed for her behavior over the past two weeks.
  • Steps:
    1. Observe Behavior: The nurse observes Mary appearing slow and fidgety during several interactions over the past two weeks.
    2. Determine Frequency: Mary exhibits these behaviors on more than half the days in the past two weeks.
    3. Document and Code: The nurse documents Mary’s behavior and codes D0500H2 as "2".
  • Outcome: Mary’s behavior of being slow, fidgety, or restless is 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 D0500H2 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.