F0800I: Staff Assessment - Discuss Care with Family/Other, Step-by-Step
Step-by-Step Coding Guide for Item Set F0800I: Staff Assessment - Discuss Care with Family/Other
1. Review of Medical Records
- Objective: To gather relevant information about the resident's interactions regarding care discussions with family or others.
- Steps:
- Collect Records: Gather all relevant medical records, including progress notes, interdisciplinary team (IDT) meeting notes, and care plan meeting summaries.
- Identify Interactions: Look for documented instances where care was discussed with the resident's family or other significant individuals.
- Verify Information: Cross-check the identified interactions to ensure consistency and accuracy in the records.
2. Understanding Definitions
- Discuss Care with Family/Other: This refers to instances where staff members engage in conversations with the resident's family or other significant persons about the resident's care plan, health status, treatment options, or any other relevant aspects of care.
3. Coding Instructions
- Steps:
- Locate Item Set: Find item set F0800I on the MDS form.
- Confirm Discussions: Ensure there are documented instances of care discussions with the resident’s family or others in the medical records.
- Determine Frequency: Assess the frequency of these discussions based on the documentation.
- Code the Item:
- 0: None
- 1: Rarely or occasionally
- 2: Frequently
- 3: Almost always
- Complete Entry: Double-check the entry for accuracy and completeness.
4. Coding Tips
- Consistent Documentation: Ensure that discussions with family or others are consistently documented in the progress notes or IDT meeting summaries.
- Clear Definitions: Understand the definitions of each frequency code to accurately represent the documented interactions.
- Documentation Details: Make sure the documentation includes the date, time, participants, and key points discussed during the interactions.
5. Documentation
- Required:
- MDS Form: Correctly filled entry for item set F0800I indicating the frequency of care discussions with family or others.
- Progress Notes: Detailed notes from staff members documenting the discussions with family or others.
- IDT Meeting Notes: Summaries from interdisciplinary team meetings where family or others were present and involved in care discussions.
- Care Plan Meeting Summaries: Documentation from care plan meetings that include family or others in the discussions.
6. Common Errors to Avoid
- Incomplete Documentation: Avoid coding this item if there are no detailed records of discussions with family or others.
- Inaccurate Frequency: Ensure the coded frequency accurately reflects the documented interactions.
- Lack of Verification: Do not code based on assumptions; verify the interactions through consistent documentation.
7. Practical Application
- Example:
- Resident Background: Mr. John Smith has frequent discussions about his care plan with his daughter, documented in the progress notes and IDT meeting summaries.
- Review Process: Access Mr. Smith’s medical records, including progress notes and IDT meeting summaries.
- Verification: Confirm the frequency of care discussions through multiple documented sources.
- Coding Process:
- Step 1: Locate item set F0800I on the MDS form.
- Step 2: Confirm the presence of documented care discussions with Mr. Smith’s daughter.
- Step 3: Determine the frequency based on documentation.
- Step 4: Enter the code representing the frequency (e.g., “3” for almost always).
- Step 5: Verify the entry with the documentation.
- Illustration:
- Provide a sample MDS form showing item set F0800I with the correct frequency code entered.
- Include an example of a progress note documenting a care discussion with Mr. Smith’s daughter.
Please note that the information provided in this guide for MDS 3.0 Item set F0800I 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.
