Step-by-Step Coding Guide for Item Set E0200C: Other Behavioral Symptoms Not Directed Toward Others

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s behavioral symptoms not directed toward others.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, behavioral health reports, care plans, and previous assessments.
  2. Identify Relevant Behaviors: Look for documented instances of behavioral symptoms that are not directed toward others, such as repetitive actions, self-talk, pacing, or other self-directed behaviors.
  3. Confirm Details: Verify the consistency of these behaviors through various sources within the medical records.

2. Understanding Definitions

• Other Behavioral Symptoms Not Directed Toward Others: Refers to behaviors that may be disruptive or concerning but are not targeted at other individuals. Examples include pacing, self-talking, rocking, and other repetitive movements or self-directed actions.
• Key Points:
  • These behaviors are often signs of internal distress or anxiety.
  • They are not aggressive or harmful to others.

3. Coding Instructions

• Steps:
  1. Observe and Document: During the assessment period, observe and document the resident’s behaviors that are not directed toward others.
  2. Determine Frequency: Identify the frequency with which these behaviors occur using the following scale:
     • 0: Behavior not exhibited
     • 1: Behavior of this type occurred 1 to 3 days
     • 2: Behavior of this type occurred 4 to 6 days, but less than daily
     • 3: Behavior of this type occurred daily
  3. Code Appropriately: Enter the corresponding code in item set E0200C 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 and examples of behavioral symptoms not directed toward others.
• 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 behavioral symptoms not directed toward others.
  • Staff Reports: Include reports from staff members detailing their observations and interactions with the resident regarding these behaviors.
  • Assessment Summary: Summarize the resident’s behavioral symptoms 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 behavioral symptoms are thoroughly documented.
• Assumptions: Do not assume the resident’s behavior without proper documentation and observation.

7. Practical Application

• Example:
  • Resident Profile: Alice, an 85-year-old resident, is being assessed for her behavioral symptoms over the past two weeks.
  • Steps:
    1. Observe Behavior: The nurse observes Alice pacing and talking to herself on several occasions during the assessment period.
    2. Determine Frequency: Alice exhibits these behaviors 4 to 6 days within the assessment period, but not daily.
    3. Document and Code: The nurse documents Alice’s behavior and codes E0200C as "2".
  • Outcome: Alice’s behavioral symptoms not directed toward others are accurately documented and coded, ensuring proper follow-up and inclusion in her care plan.

Please note that the information provided in this guide for MDS 3.0 Item set E0200C 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.