Step-by-Step Coding Guide for Item Set F0800A: Staff Assessment: Choosing Clothes to Wear

1. Review of Medical Records

• Objective: Accurately determine and document the resident's ability to choose clothes to wear as part of the staff assessment.
• Steps:
  1. Collect Information: Gather comprehensive medical records, including nursing notes, care plans, occupational therapy assessments, and previous functional assessments.
  2. Identify Documentation of Choosing Clothes: Look for documented instances where the resident’s ability to choose clothes was assessed or observed.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Choosing Clothes to Wear: Refers to the resident’s ability to select appropriate clothing for the day, considering weather conditions, personal preferences, and social norms.
• Staff Assessment: An evaluation conducted by staff to determine the resident’s functional abilities.
• Key Points:
  • Independence: The degree of assistance the resident requires to choose their clothes.
  • Performance: Focuses on the resident’s actual ability during the specified assessment period, not their potential ability or past performance.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the resident’s ability to choose clothes during the assessment period.
  2. Verify Documentation: Ensure that the resident's performance in choosing clothes is clearly noted in the records, including the level of assistance required.
  3. Code Appropriately: Enter the appropriate code for the resident’s ability to choose clothes in item set F0800A based on their level of independence:
     • 0: Independent - Resident chooses clothes without any help.
     • 1: Supervision - Resident needs verbal cueing or supervision.
     • 2: Limited Assistance - Resident needs physical assistance with choosing appropriate clothes.
     • 3: Extensive Assistance - Resident needs significant help in selecting clothes.
     • 4: Total Dependence - Resident cannot choose clothes and needs full assistance.
     • 8: Activity did not occur - The resident did not engage in choosing clothes during the assessment period.

4. Coding Tips

• Accurate Identification: Ensure the resident’s performance is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s ability to choose clothes.
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes from nursing staff documenting the resident’s performance in choosing clothes.
  • Care Plans: Outlining the level of assistance the resident needs in daily activities, including choosing clothes.
  • Occupational Therapy Assessments: Assessments from occupational therapists detailing the resident’s ability to choose appropriate clothing.
  • Previous Functional Assessments: Any previous assessments that have documented the resident’s ability to choose clothes.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s performance through multiple records and notes.
• Incomplete Documentation: Make sure all relevant nursing notes, care plans, and occupational therapy assessments are included to support the documented ability.
• Assumptions: Do not assume the resident’s ability without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: John, an 85-year-old resident, has mild cognitive impairment and was assessed during the staff assessment period for his ability to choose clothes to wear.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, noting the occupational therapy assessment and nursing notes documenting John’s ability to choose clothes.
    2. Identify Performance: It is confirmed through the documentation that John requires supervision to choose appropriate clothes.
    3. Document and Code: The nurse documents John’s performance in his records and codes F0800A as "1".
  • Outcome: John’s ability to choose clothes with supervision is 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 F0800A 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.