Step-by-Step Coding Guide for Item Set E0500A: Behavioral Symptoms Put Resident at Risk for Illness/Injury

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s behavioral symptoms that may put them at risk for illness or injury.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, nursing notes, behavioral health assessments, care plans, and incident reports.
  2. Identify Behavioral Symptoms: Look for documented instances of behavioral symptoms such as aggression, wandering, self-harm, or other behaviors that could pose a risk to the resident’s health and safety.
  3. Confirm Details: Verify the consistency and accuracy of the documentation through various sources within the medical records.

2. Understanding Definitions

• Behavioral Symptoms: Actions or behaviors exhibited by the resident that could potentially cause harm or increase the risk of illness or injury. This includes aggression, self-injurious behavior, wandering, or other risky behaviors.
• Risk for Illness/Injury: The potential for the resident’s behavior to lead to physical harm or exacerbate existing health conditions.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm the resident’s behavioral symptoms that put them at risk for illness or injury based on medical records and staff observations.
  2. Verify Documentation: Ensure the behavioral symptoms and associated risks are clearly documented in the resident’s records, including specific instances and descriptions of the behaviors.
  3. Code Appropriately: Use the following scale to code the resident’s behavioral symptoms that put them at risk:
     • 0: No
     • 1: Yes

4. Coding Tips

• Accurate Observation: Ensure that staff are trained to accurately observe and document the resident’s behavioral symptoms.
• Clarify Definitions: Make sure the staff understands what constitutes a behavioral symptom that puts the resident at risk for illness or injury.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s behavioral symptoms and associated risks.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes from nursing staff documenting the resident’s behavioral symptoms and the associated risks during the assessment period.
  • Behavioral Health Assessments: Regular entries detailing the frequency, intensity, and impact of the resident’s behavioral symptoms.
  • Physician Notes: Documentation from physicians regarding assessments and interventions related to the resident’s behavioral symptoms.
  • Care Plans: Include information about the resident’s behavioral health management plan and any interventions used to mitigate risks.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the behavioral symptoms and associated risks through multiple records and observations.
• Incomplete Documentation: Make sure all relevant notes and logs are included.
• Assumptions: Do not assume the presence or absence of risk without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Jane, an 80-year-old resident, has been exhibiting aggressive behavior and wandering tendencies, which pose a risk to her health and safety.
  • Steps:
    1. Review Records: The nurse reviews Jane’s medical records, including nursing notes and behavioral health assessments that document her aggressive behavior and wandering.
    2. Identify Risk: It is confirmed that Jane’s behavior puts her at risk for injury, such as falls or confrontations with other residents.
    3. Document and Code: The nurse documents Jane’s behavioral symptoms and associated risks in her records and codes E0500A as "1".
  • Outcome: Jane’s behavioral symptoms and the risks they pose 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 E0500A 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.