Step-by-Step Coding Guide for Item Set F0800D: Staff Assessment - Receiving Shower

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s receiving of showers.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including care plans, nursing notes, bathing schedules, and previous assessments.
  2. Identify Shower Documentation: Look for documented instances of the resident receiving showers, including frequency and assistance required.
  3. Confirm Details: Verify the consistency and accuracy of the documentation through various sources within the medical records.

2. Understanding Definitions

• Receiving Shower: The act of the resident being bathed using a shower, either independently or with assistance from staff.
• Key Points:
  • Receiving a shower involves the resident being fully bathed using a showerhead, typically in a shower stall or bathroom.
  • The assessment should account for the frequency and the level of assistance required by the resident.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm that the resident has received showers based on medical records and care plans.
  2. Verify Documentation: Ensure the frequency and level of assistance for showering are clearly documented in the resident’s records.
  3. Code Appropriately: Use the following scale to code the resident’s receiving of showers:
     • 0: Resident did not receive any showers during the assessment period.
     • 1: Resident received showers less than daily.
     • 2: Resident received showers daily.

4. Coding Tips

• Accurate Identification: Ensure the documentation explicitly mentions the resident receiving a shower and the frequency of showers.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s showering activity.
• Consult Caregivers: If there is any uncertainty, consult with the caregivers or nursing staff for clarification.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes from nursing staff documenting the resident’s showering schedule and assistance required.
  • Care Plans: Include information about the resident’s bathing routine, specifying the frequency and type of assistance.
  • Bathing Schedules: Documentation of the scheduled and actual showering times for the resident.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the showering frequency and assistance required through multiple records and consultations.
• Incomplete Documentation: Make sure all relevant notes and schedules are included.
• Assumptions: Do not assume the showering frequency without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: John, an 85-year-old resident, receives assistance from nursing staff for his showers.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, including care plans and nursing notes that document his showering schedule.
    2. Identify Frequency: It is confirmed that John receives showers three times a week with assistance.
    3. Document and Code: The nurse documents John’s showering schedule in his records and codes F0800D as "1".
  • Outcome: John’s showering schedule 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 F0800D 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.