Step-by-Step Coding Guide for Item Set F0800K: Staff Assessment - Place to Lock Personal Things

Step-by-Step Coding Guide for Item Set F0800K: Staff Assessment - Place to Lock Personal Things

1. Review of Medical Records

• Objective: To determine if the resident has a place to lock personal belongings.
• Process:
  • Admission Records: Review the resident's admission records where information about personal storage might be documented.
  • Care Plan: Check the resident’s care plan for notes about securing personal items.
  • Interviews: Conduct interviews with the resident, family members, and staff to confirm the availability of a secure place for personal belongings.
  • Facility Policies: Review facility policies regarding the provision of locked storage for residents.

2. Understanding Definitions

• Place to Lock Personal Things: Refers to a secure, lockable space provided to the resident to store personal items. This can include lockable drawers, cabinets, or personal safes.
• Staff Assessment: The process by which staff evaluate and document the resident’s access to secure storage.

3. Coding Instructions

• Code F0800K:
  • 0: No, the resident does not have a place to lock personal things.
  • 1: Yes, the resident has a place to lock personal things.
• Example: If the resident has a lockable drawer in their room where they can store personal items securely, code F0800K as '1'.

4. Coding Tips

• Verification: Confirm through direct observation or interview that the resident has access to a lockable space.
• Documentation Consistency: Ensure that the information about lockable storage is consistently documented across all relevant records.

5. Documentation

• Required Documentation:
  • Care Plan: Document the provision and location of the lockable storage in the resident’s care plan.
  • Interview Notes: Include notes from interviews with the resident and staff confirming the availability of a secure place.
  • Facility Records: Ensure that facility records or policies about personal storage are referenced.
• Example: "During the assessment on 05/10/2024, it was confirmed that the resident has a lockable drawer in their bedside table for storing personal items. This is documented in the resident’s care plan and confirmed by the resident during an interview."

6. Common Errors to Avoid

• Assumptions: Do not assume the availability of secure storage without verification.
• Incomplete Documentation: Ensure all necessary documentation is completed and consistently updated.
• Failure to Confirm: Always confirm the presence of lockable storage through direct observation or reliable sources.

7. Practical Application

• Scenario: A resident reports concerns about the security of their personal items. The staff conducts an assessment and confirms that a lockable drawer is available and functional in the resident’s room. This information is documented in the care plan, and the resident is informed about the availability of the lockable space. Based on this assessment, F0800K is coded as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set F0800K 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.