Step-by-Step Coding Guide for Item Set F0800M: Staff Assessment: Listening to Music

1. Review of Medical Records

• Objective: Gather comprehensive information about the resident’s involvement in listening to music.
• Steps:
  1. Access Records: Retrieve the resident’s medical records, care plans, activity logs, and staff notes.
  2. Identify Music-Related Activities: Look for documentation that details the resident’s participation in music listening activities, including the frequency and duration.
  3. Confirm Staff Assessment: Verify that the staff has assessed the resident’s participation in listening to music and documented it accurately.

2. Understanding Definitions

• Listening to Music: This refers to the resident engaging in activities where they are listening to music either through headphones, speakers, or live performances.
• Staff Assessment: An evaluation conducted by the staff to determine the resident’s level of participation and enjoyment in listening to music.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set F0800M on the MDS form.
  2. Assess Music Listening Participation: Review the staff notes and activity logs to evaluate how often the resident listens to music.
  3. Code the Item:
     • 0: No participation.
     • 1: Rarely or never listens to music.
     • 2: Listens to music one to three times a month.
     • 3: Listens to music one to two times a week.
     • 4: Listens to music three to six times a week.
     • 5: Listens to music daily.
  4. Complete Entry: Enter the appropriate code in the designated field for item set F0800M.

4. Coding Tips

• Consistent Documentation: Ensure staff consistently document the resident’s participation in music listening activities.
• Resident Preferences: Take into account the resident’s preferences and willingness to participate in listening to music.
• Cross-Verify: Cross-check information from different sources (e.g., care plans, activity logs) to ensure accuracy.

5. Documentation

• Required:
  • Activity Logs: Records detailing the resident’s participation in listening to music, including frequency and duration.
  • Staff Notes: Observations and assessments by staff regarding the resident’s engagement with music.
  • MDS Form: Correctly completed entry for item set F0800M, reflecting the resident’s level of participation.

6. Common Errors to Avoid

• Inconsistent Documentation: Avoid discrepancies in records regarding the resident’s participation in listening to music.
• Assumptions: Do not make assumptions about participation without documented evidence.
• Omitting Information: Ensure all relevant information about the resident’s participation is documented and considered.

7. Practical Application

• Example:
  • Resident Background: Mr. John Smith enjoys listening to classical music. Staff have noted his participation in music listening activities over the assessment period.
  • Review Process: Examine Mr. Smith’s activity logs and staff notes, focusing on documented instances of him listening to music.
  • Coding Process:
    • Step 1: Locate item set F0800M on the MDS form.
    • Step 2: Review documented evidence to determine Mr. Smith’s frequency of listening to music.
    • Step 3: Enter the appropriate code (e.g., “4” if Mr. Smith listens to music three to six times a week) in the designated field.
    • Step 4: Document the process and ensure consistency with the activity logs and staff notes.
  • Illustration:
    • Provide a sample MDS form showing item set F0800M with the appropriate code entered, accompanied by excerpts from the activity logs highlighting documented instances of music listening.

Please note that the information provided in this guide for MDS 3.0 Item set F0800M 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.