Step-by-Step Coding Guide for Item Set F0400E: Resident Interview: Choose Own Bedtime

1. Review of Medical Records

• Objective: Ensure accurate coding for the resident’s ability to choose their own bedtime.
• Steps:
  1. Access Records: Retrieve the resident's comprehensive medical records and recent assessments.
  2. Identify Relevant Information: Locate any documentation or notes from staff regarding the resident’s bedtime preferences and choices.
  3. Verify Interview Notes: Confirm that there is a documented resident interview addressing their ability to choose their own bedtime.

2. Understanding Definitions

• Choose Own Bedtime: Refers to the resident’s autonomy in deciding when to go to bed, rather than adhering to a facility-imposed schedule.
• Resident Interview: A direct interaction where the resident is asked about their preferences and routines, including their control over bedtime decisions.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set F0400E on the MDS form.
  2. Conduct the Interview:
     • Ensure the interview is conducted with the resident, focusing on their bedtime choices.
     • Ask the resident directly if they are able to choose their own bedtime.
  3. Code the Item:
     • Response Options:
       • 0: No, the resident does not choose their own bedtime.
       • 1: Yes, the resident chooses their own bedtime.
     • Mark the appropriate response based on the resident's answer.
  4. Complete Entry: Ensure the correct coding of the resident’s response in the designated field for item set F0400E.

4. Coding Tips

• Verification: Always confirm the resident’s response with them directly during the interview.
• Clarity: Clearly document the resident’s response and ensure there is no ambiguity.
• Accuracy: Double-check the marked box to ensure it accurately reflects the resident’s response.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set F0400E indicating the resident’s ability to choose their own bedtime.
  • Interview Notes: Detailed notes from the resident interview about their bedtime preferences.
  • Verification Logs: Logs or records verifying the interview and the resident’s response.

6. Common Errors to Avoid

• Incorrect Marking: Ensure the correct response is marked based on the resident’s answer.
• Incomplete Interviews: Avoid coding without a proper interview and documented response from the resident.
• Inconsistent Records: Ensure that all related records and assessments reflect the resident's reported preferences.

7. Practical Application

• Example:
  • Resident Background: Mrs. Jane Doe is interviewed regarding her bedtime preferences.
  • Review Process: Access Mrs. Doe’s medical records and assessments.
  • Verification: Confirm the documentation of the resident’s bedtime preferences.
  • Coding Process:
    • Step 1: Locate item set F0400E on the MDS form.
    • Step 2: Conduct the interview and ask Mrs. Doe if she can choose her own bedtime.
    • Step 3: Mark the box based on Mrs. Doe’s response (e.g., she confirms she chooses her own bedtime).
    • Step 4: Ensure all records are consistent and documented.
  • Illustration:
    • Provide a sample MDS form showing item set F0400E with the box marked for the resident choosing their own bedtime.
    • Include a screenshot or example of the interview notes indicating the resident’s preference.

Please note that the information provided in this guide for MDS 3.0 Item set F0400E 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.