Step-by-Step Coding Guide for E1100. Change in Behavior or Other Symptoms

1. Review of Medical Records

Start by thoroughly reviewing the resident's medical records, focusing on any documented changes in behavior, mood, or psychological symptoms. Look for notes from physicians, nursing staff, and other healthcare professionals. This includes new behaviors, increased frequency or severity of existing behaviors, or any reports from family members about changes noticed during visits.

2. Understanding Definitions

• Behavioral Symptoms: This includes aggression, agitation, resistance to care, or any other symptoms that may impact the resident's care.
• Psychological Symptoms: This refers to internal experiences such as hallucinations, delusions, anxiety, or depression.
• Change: A noticeable difference in the resident's behavior or psychological symptoms when compared to their usual status, which is relevant to their overall care plan.

3. Coding Instructions

• Code 0 (Behavior not exhibited): If the resident shows no change in behavior or other symptoms in the last 30 days.
• Code 1 (Behavior of this type occurred): If there has been any reported or observed change in the resident’s behavior or psychological symptoms in the last 30 days.

4. Coding Tips

• Ensure any change in behavior is significant enough to impact the resident's care plan or requires intervention.
• Consider consulting with interdisciplinary team members for a comprehensive assessment of the behavior change.

5. Documentation

Document the specific changes observed or reported, including the nature of the change, frequency, severity, and any interventions implemented or planned. Ensure this documentation is thorough and updated in the resident's medical record.

6. Common Errors to Avoid

• Overlooking subtle changes: Some changes may be subtle and not immediately evident without careful observation or communication with the resident.
• Misinterpreting behaviors: Ensure accurate interpretation by considering the resident's baseline behavior and medical history.
• Inadequate documentation: Failing to document all relevant details about the behavior change can impact the care planning process.

7. Practical Application

• Example Scenario: A resident who is usually calm becomes agitated and verbally aggressive towards staff during care routines. After reviewing the medical records and consulting with the care team, you note the behavior change started two weeks ago and has been increasing in frequency. Code this behavior as 1 (Behavior of this type occurred), and document the specific changes, potential triggers, and interventions tried or planned.

The Step-by-Step Coding Guide for item E1100 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.