Step-by-Step Coding Guide for E0500. Impact on Resident

1. Review of Medical Records

• Begin by reviewing the resident's medical records thoroughly, focusing on documentation related to mood, behaviors, and psychological symptoms.
• Look for notes from healthcare providers, psychologists, psychiatrists, or any mental health professionals involved in the resident's care.
• Pay attention to any documented changes in mood, instances of sadness, anxiety, or other emotional distress that affect the resident’s daily functioning.

2. Understanding Definitions

• Impact on Resident: Refers to how symptoms of mood (sadness, anxiety, etc.) have affected the resident's functional status, social interactions, and overall participation in activities of daily living.
• Significant Change: A noticeable alteration in the resident's mood or behavior patterns that influences their daily life.

3. Coding Instructions

• Code 0: No impact. Symptoms do not affect resident's functioning or are managed effectively.
• Code 1: Symptoms affect resident's functioning but not in all aspects. May impact certain activities or interactions.
• Code 2: Symptoms significantly affect resident's functioning in most areas. May see withdrawal from activities or significant changes in social interactions.

4. Coding Tips

• Utilize a multidisciplinary approach, involving nursing, therapy, and social services, to gather comprehensive information on the resident's mood and its impact.
• Consider family input or direct observations if the resident has difficulty expressing their feelings or the extent of the impact.

5. Documentation

• Document your findings and coding decisions in the resident's medical record, including specific examples of how mood symptoms have impacted their functioning.
• Note any interventions in place or planned to address the identified issues.

6. Common Errors to Avoid

• Overlooking subtle signs of mood impact, such as decreased social interaction or reduced participation in previously enjoyed activities.
• Failing to consider the effectiveness of interventions already in place.

7. Practical Application

Example: A resident who used to participate in group activities now prefers to stay in their room due to feelings of sadness and anxiety. Despite medication, the resident expresses feelings of hopelessness and has difficulty engaging in daily routines.

• Coding: Based on the significant impact on the resident's social participation and daily function, this scenario would be coded as 2.

The Step-by-Step Coding Guide for item B0100 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.