Step-by-Step Coding Guide for Item Set F0800N: Staff Assessment: Being Around Animals/Pets

1. Review of Medical Records

• Objective: Accurately assess and document the resident's interaction with animals/pets as part of their routine activities.
• Steps:
  1. Collect Information: Gather comprehensive medical records, including care plans, activity logs, staff notes, and any previous assessments of the resident’s interaction with animals or pets.
  2. Identify Documentation of Animal/Pet Interaction: Look for documented instances where the resident has interacted with animals or pets, noting frequency and resident responses.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Being Around Animals/Pets: Refers to the resident's interaction with animals or pets, which may include pet therapy sessions, visits from therapy animals, or time spent with facility pets.
• Key Points:
  • Interaction: Can include petting, feeding, talking to, or simply being in the presence of animals or pets.
  • Benefits: Interaction with animals can provide emotional, psychological, and sometimes physical benefits to residents.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the resident’s interaction with animals or pets, supported by staff notes and activity logs.
  2. Verify Documentation: Ensure that the documentation clearly notes the frequency and nature of the interactions.
  3. Code Appropriately: Enter the appropriate code for item set F0800N based on the resident’s interaction with animals or pets:
     • 0: No, the resident does not spend time around animals or pets.
     • 1: Yes, the resident spends time around animals or pets.

4. Coding Tips

• Accurate Identification: Ensure the interaction with animals or pets is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the interaction with animals or pets.
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Staff Notes: Detailed notes from staff documenting the resident’s interaction with animals or pets.
  • Activity Logs: Logs detailing the resident’s participation in activities involving animals or pets.
  • Care Plans: Including any interventions or strategies to incorporate animal interaction into the resident’s routine.
  • Previous Assessments: Any previous assessments that have documented the resident’s interaction with animals or pets.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s interaction through multiple records and notes.
• Incomplete Documentation: Make sure all relevant notes and activity logs are included to support the documented interaction.
• Assumptions: Do not assume the resident’s interaction with animals or pets without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Emily, an 85-year-old resident, regularly participates in weekly pet therapy sessions with a therapy dog.
  • Steps:
    1. Review Records: The nurse reviews Emily’s medical records, noting the staff notes and activity logs documenting her weekly pet therapy sessions.
    2. Identify Interaction: It is confirmed through the documentation that Emily spends time around animals/pets.
    3. Document and Code: The nurse documents the interaction in Emily’s records and codes F0800N as "1".
  • Outcome: Emily’s interaction with animals/pets 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 F0800N 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.