C0900. Memory/Recall Ability

Step-by-Step Coding Guide for Item Set C0900: Memory/Recall Ability

1. Review of Medical Records

Before coding C0900, review the resident's medical record for documented evidence of memory and recall ability. Look for notes from healthcare professionals, results from cognitive assessments, and any relevant diagnoses that may impact memory function.

2. Understanding Definitions

Short-term Memory: The ability to recall information from a few minutes to several days. It involves remembering recent events or instructions. Long-term Memory: Involves recalling information from the distant past, such as personal history, past events, or learned facts.

3. Coding Instructions

Code the resident’s memory/recall ability by observing or interacting with them. Ask simple questions related to both short-term and long-term memory. For example, for short-term memory, you might ask about meals eaten that day; for long-term memory, inquire about significant life events.

• Code 0 - Independent: The resident recalls long-term and short-term events without cues.
• Code 1 - Modified Independence: The resident recalls with cues or prompts (e.g., "What did you have for breakfast this morning? Was it eggs?").
• Code 2 - Moderately Impaired: The resident has limited recall of recent events, even with cues. Long-term memory may be intact.
• Code 3 - Severely Impaired: The resident is unable to recall recent events, even with cues, and has difficulty recalling their personal history.

4. Coding Tips

• Utilize a variety of questions to assess both types of memory.
• Ensure the environment is free from distractions during assessment.
• Pay attention to the resident's ability to recall with or without cues.

5. Documentation

Document the resident's responses and your coding decision in their medical record. Note the type of questions asked, the resident’s responses, and any cues or prompts provided.

6. Common Errors to Avoid

• Overestimating Ability: Don't assume ability based on a single correct answer. Use a variety of questions.
• Underestimating Ability: Recognize when a resident can recall with cues, indicating not a complete loss of memory.
• Ignoring Cues: Failing to note when a resident successfully recalls information with cues can lead to inaccurate coding.

7. Practical Application

• Example Scenario: A resident correctly recalls their daughter's name and that they had coffee for breakfast after being prompted but struggles to recall other recent meals or events.
  • Coding: This scenario suggests "Code 1 - Modified Independence" as the resident can recall with cues.

The Step-by-Step Coding Guide for item C0900 in MDS 3.0 Section C is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.