D0150C1: PHQ Resident Mood Interview - Trouble with Sleep: Presence, Step-by-Step

Step-by-Step Coding Guide for D0150C1: PHQ Resident Mood Interview – "Trouble with Sleep: Presence"

1. Review of Medical Records

Objective: Determine if the resident has experienced trouble with sleep, such as difficulty falling or staying asleep or sleeping too much, as part of the PHQ-9 Resident Mood Interview.

Actions:

• Review the resident’s sleep patterns from recent care notes or assessments if available.
• Conduct the PHQ-9 Resident Mood Interview, focusing on asking the resident about trouble with sleep over the past two weeks.
• Record the resident's response on whether they have experienced this issue.

2. Understanding Definitions

D0150C1: Trouble with Sleep – Presence assesses whether the resident has had trouble falling asleep, staying asleep, or feels that they sleep too much.

Example Scenario:

• Resident A: States, "I’ve had trouble staying asleep most nights recently." This response confirms the presence of the symptom and would be coded as 1: Yes (symptom present).

3. Coding Instructions

Step-by-Step:

• Step 1: Ask the resident, “Over the past two weeks, have you been bothered by trouble falling or staying asleep or sleeping too much?”
• Step 2: Code based on the resident's response:
  • 1: Yes – If the resident confirms that they experienced trouble with sleep.
  • 0: No – If the resident denies having trouble with sleep.
  • 9: No response – If the resident is unable or unwilling to answer.

4. Coding Tips

• Clarify Responses: If the resident provides a vague answer, ask follow-up questions to clarify whether they had trouble with sleep and how often.
• No Assumptions: Do not assume the presence of the symptom based on observations. Always rely on the resident's own reporting unless they are unable to respond.

5. Documentation

Objective: Record the resident's experience with trouble falling or staying asleep or sleeping too much to help assess mood and potential depression.

Actions:

• Document the resident's response, noting whether they have experienced any sleep disturbances.
• If the symptom is present, follow up with additional questions to assess frequency (D0150C2) and document these findings accordingly.

6. Common Errors to Avoid

• Skipping the Question: Always ask the resident about their sleep patterns, even if no prior indication of trouble has been documented.
• Assuming Based on Observation: Do not code based on assumptions or external observations unless the resident cannot respond.

7. Practical Application

Example 1:
The resident reports having trouble falling asleep most nights during the last two weeks. This should be coded as 1: Yes.

Example 2:
A resident denies any trouble with sleep, stating they sleep well. This should be coded as 0: No.

Please note that the information provided in this guide for MDS 3.0 Item set D0150C1 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.