Step-by-Step Coding Guide for Item Set F0800H: Staff Assessment - Staying Up Past 8 PM

Step-by-Step Coding Guide for Item Set F0800H: Staff Assessment - Staying Up Past 8 PM

1. Review of Medical Records

• Objective: Identify if the resident typically stays up past 8 PM.
• Process:
  • Daily Activity Logs: Check logs for recorded bedtime routines.
  • Nursing Notes: Look for entries that document the resident’s sleep patterns.
  • Care Plan: Review the care plan to see if staying up past 8 PM is noted as part of the resident’s usual routine.
  • Resident Interviews: Consider documented responses from the resident or family about usual bedtime preferences.

2. Understanding Definitions

• Staying Up Past 8 PM: This item assesses whether the resident usually stays awake past 8 PM, indicating their preferred bedtime routine and ensuring the care plan respects their lifestyle choices.

3. Coding Instructions

• Code F0800H:
  • 0: No, the resident does not usually stay up past 8 PM.
  • 1: Yes, the resident usually stays up past 8 PM.
• Example: If a resident typically watches TV until 9 PM every night, code F0800H as '1'.

4. Coding Tips

• Consistent Documentation: Ensure that the bedtime routine is consistently documented in all relevant records.
• Interdisciplinary Input: Confirm the resident’s routine with inputs from all relevant staff members, including night shift nurses and caregivers.

5. Documentation

• Required Documentation:
  • Activity Logs: Entries showing the resident’s bedtime.
  • Nursing Notes: Consistent notes about the resident’s sleep routine.
  • Care Plan: Reflects the resident’s preference for staying up past 8 PM.
• Example: "Nursing notes from the past month show that the resident consistently stays up until 9 PM to watch their favorite TV show. The care plan has been adjusted to reflect this preference."

6. Common Errors to Avoid

• Assuming Routine: Do not assume the resident’s routine without documented evidence.
• Inconsistent Records: Ensure all documentation consistently reflects the resident’s routine.
• Overlooking Preferences: Make sure resident preferences are respected and documented correctly.

7. Practical Application

• Scenario: A resident enjoys reading until 9 PM each night. The nursing staff documents this routine in the daily activity logs and updates the care plan to reflect the resident’s preference. Thus, F0800H is coded as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set F0800H 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.