E0100. Potential Indicators of Psychosis

Step-by-Step Coding Guide for E0100. Potential Indicators of Psychosis

1. Review of Medical Records

Before coding E0100, review the resident's medical records for evidence of potential indicators of psychosis, such as physician notes, nursing notes, psychiatric evaluations, and any relevant diagnoses or observations of behaviors that may suggest hallucinations, delusions, or other psychotic symptoms.

2. Understanding Definitions

• Hallucinations: Perceptions that occur without an actual external stimulus, such as hearing voices or seeing things that are not present.
• Delusions: Fixed false beliefs that are not based on reality or cultural norms, such as believing one has superpowers or is being persecuted without evidence.

3. Coding Instructions

• Code 0, No: if the resident has not exhibited any behaviors indicative of hallucinations or delusions during the 7-day look-back period.
• Code 1, Yes: if the resident has exhibited behaviors that may suggest hallucinations or delusions during the 7-day look-back period.

4. Coding Tips

• Pay close attention to the descriptions of behaviors in the medical records and during observations. Note that some behaviors might be subtle and require careful assessment.
• Consult with interdisciplinary team members who have interacted with the resident to gather a comprehensive understanding of the resident's behaviors.

5. Documentation

Document specific instances of potential indicators of psychosis, including the date, time, and a detailed description of the behavior observed. This documentation should support the coding decision and can be useful for care planning and follow-up assessments.

6. Common Errors to Avoid

• Overlooking subtle signs of psychosis, such as mild or infrequent hallucinations or delusions.
• Confusing delirium or cognitive impairment with psychosis without thorough assessment.
• Failing to consider input from various sources, including family members or other caregivers who may have observed relevant behaviors.

7. Practical Application

Example: A resident, Mrs. Smith, has been reported by the nursing staff to occasionally talk to her deceased husband, especially in the evenings. Upon review of her medical record, it is noted that she has a diagnosis of schizophrenia with a history of auditory hallucinations. The interdisciplinary team confirms these observations align with her known psychiatric condition.

• Action: Code E0100 as 1, Yes, because Mrs. Smith has exhibited behaviors consistent with hallucinations during the look-back period. The care plan should include strategies to address her symptoms and provide support, potentially including psychiatric consultation and therapeutic interventions.

The Step-by-Step Coding Guide for item E0100 in MDS 3.0 Section E is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.