D0150C2: PHQ Resident: Trouble with Sleep - Frequency, Step-by-Step

Step-by-Step Coding Guide for Item Set D0150C2: PHQ Resident: Trouble with Sleep - Frequency

1. Review of Medical Records

• Objective: Gather relevant information about the resident's sleep patterns and frequency of trouble with sleep.
• Steps:
  1. Collect Records: Obtain the resident’s medical records, including sleep logs, nursing notes, and previous assessments.
  2. Identify Sleep Issues: Look for documentation specifically mentioning trouble with sleep, such as difficulty falling asleep, staying asleep, or waking up too early.
  3. Verify Frequency: Determine the frequency of sleep issues as noted in the records (e.g., daily, several times a week, etc.).

2. Understanding Definitions

• Trouble with Sleep: Difficulties related to falling asleep, staying asleep, or waking up earlier than desired.
• Frequency: How often the resident experiences trouble with sleep, categorized by specific intervals.

3. Coding Instructions

• Steps:
  1. Determine Frequency: Identify the exact frequency of sleep trouble using the following scale:
     • 0: Never or 1 day
     • 1: 2-6 days
     • 2: 7-11 days
     • 3: 12-14 days
  2. Record Frequency: Enter the appropriate code (0-3) based on the documented frequency in the resident’s medical records.

4. Coding Tips

• Detailed Documentation: Ensure that all instances of sleep trouble are thoroughly documented with specific dates and descriptions.
• Consistent Review: Cross-check different sources of documentation to confirm the frequency of sleep trouble.
• Resident Interviews: When possible, use direct interviews with the resident to supplement documented information.

5. Documentation

• Required:
  • Sleep Logs: Logs maintained by nursing staff or provided by the resident, detailing sleep patterns.
  • Nursing Notes: Notes that describe observations and reports of sleep issues.
  • Previous Assessments: Previous MDS assessments that include information about sleep patterns.

6. Common Errors to Avoid

• Inconsistent Information: Avoid discrepancies by cross-referencing multiple records.
• Assumptions: Do not make assumptions about the frequency without documented evidence.
• Incomplete Records: Ensure that all relevant documents are reviewed to provide an accurate frequency.

7. Practical Application

• Example:
  • Resident Profile: Jane, a resident, reports trouble with sleep occurring almost every night.
  • Steps:
    1. Review Records: The staff reviews Jane’s sleep logs and nursing notes, which document trouble with sleep on 10 of the past 14 days.
    2. Determine Frequency: Based on the scale, Jane’s trouble with sleep falls into the “7-11 days” category.
    3. Document and Code: The staff codes item D0150C2 with a “2” for 7-11 days.

Please note that the information provided in this guide for MDS 3.0 Item set D0150C2 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.