Step-by-Step Coding Guide for Item Set F0400F: Resident Interview: Discuss Care with Family/Friend

1. Review of Medical Records

• Objective: To determine if the resident had discussions about their care with family or friends as per their preference.
• Process:
  • Review the resident’s care plan and nursing notes for any documented interactions involving discussions about the resident’s care with family or friends.
  • Check social service documentation for any notes on family meetings or scheduled discussions per the resident's or family’s request.
  • Consult with the activities director and any other relevant staff who may facilitate family interactions.

2. Understanding Definitions

• Discuss Care with Family/Friend: Refers to any instance where the resident has communicated with family members or friends about their care preferences, treatment decisions, or overall well-being, as recorded in the resident’s care documentation.

3. Coding Instructions

• Code F0400F:
  • 0: No or resident did not have the opportunity.
  • 1: Yes, resident had the opportunity.
• Example: If a resident’s family members regularly participated in care planning meetings as documented, code F0400F as '1'.

4. Coding Tips

• Ensure that the discussion involved care decisions and was not just casual conversation.
• Clarify and confirm through multiple sources, including the resident and family, to ensure accuracy in coding.

5. Documentation

• Required Documentation:
  • Entries in social services or care planning meeting notes that confirm discussions with family or friends about care.
  • Resident or family feedback forms that might indicate satisfaction with these discussions.
  • Documentation in the resident’s care plan that notes resident preferences for involving family or friends in care discussions.
• Documentation should be precise, reflecting direct involvement of family or friends in discussions about the resident’s care.

6. Common Errors to Avoid

• Assuming that all family interactions involve care discussions without specific documentation.
• Overlooking or not documenting the resident's preference for including family or friends in care discussions.
• Failure to update the resident’s file when discussions about care with family or friends take place.

7. Practical Application

• Scenario: A resident expressed a desire to have her daughter involved in her care planning to ensure her preferences were communicated effectively. The facility arranged a care planning meeting where the resident, her daughter, and the care team discussed the care plan and made necessary adjustments based on the resident's preferences. This meeting was documented in the care plan notes and confirmed by the resident’s signed acknowledgment of the discussed changes. For MDS coding, based on the documentation, F0400F was accurately coded as '1', reflecting the resident’s active engagement with her family in care discussions.

Please note that the information provided in this guide for MDS 3.0 Item set F0400F 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.