F0800J: Staff Assessment: Use Phone in Private, Step-by-Step
Step-by-Step Coding Guide for Item Set F0800J: Staff Assessment: Use Phone in Private
1. Review of Medical Records
- Objective: To ensure accurate documentation of the resident's ability to use the phone in private.
- Steps:
- Access Records: Retrieve the resident’s comprehensive medical records, including care plans, social service notes, and progress notes.
- Verify Information: Look for documented evidence of the resident’s ability or inability to use the phone in private.
- Cross-Reference: Confirm consistency of this information across different sections of the medical records (e.g., nursing notes, care plans).
2. Understanding Definitions
- Use Phone in Private: Refers to the resident’s ability to make and receive phone calls in a private setting without interruptions or being overheard.
- Staff Assessment: An evaluation conducted by staff members based on observations and interactions with the resident.
3. Coding Instructions
- Steps:
- Locate Item Set: Access item set F0800J on the MDS form.
- Assess Ability: Determine if the resident can use the phone in private based on staff assessments and documented observations.
- Code the Item:
- If the resident can use the phone in private, code the item as “0” (No).
- If the resident cannot use the phone in private, code the item as “1” (Yes).
- Complete Entry: Ensure accurate documentation in the MDS form reflecting the resident’s ability to use the phone in private.
4. Coding Tips
- Accuracy: Double-check records to ensure the resident’s ability to use the phone in private is correctly documented.
- Consistency: Ensure that the information is consistent across all relevant sections of the medical records.
- Detail: Include any specific circumstances or observations related to the resident’s use of the phone.
5. Documentation
- Required:
- Medical Records: Detailed records including staff assessments, care plans, and progress notes documenting the resident’s ability to use the phone in private.
- MDS Form: Accurate completion of item set F0800J indicating the resident’s ability to use the phone in private.
- Supporting Documents: Include any additional documentation supporting the assessment (e.g., social service notes, family input).
6. Common Errors to Avoid
- Misdocumentation: Incorrectly documenting the resident’s ability to use the phone in private without proper verification.
- Incomplete Records: Missing or incomplete documentation regarding the resident’s phone use.
- Inconsistent Coding: Discrepancies between the MDS form and other sections of the resident’s medical records.
7. Practical Application
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Example:
- Resident Background: Mrs. Jane Smith frequently uses the phone to speak with her family. Staff observations confirm she can make calls in private.
- Review Process: Upon review, her medical records include social service notes indicating her ability to use the phone in private.
- Coding Process:
- Step 1: Access the MDS form and locate item set F0800J.
- Step 2: Assess staff observations and documentation confirming her ability to use the phone in private.
- Step 3: Code the item as “0” (No) to indicate that Mrs. Smith can use the phone in private.
- Step 4: Document the assessment and any relevant observations in the MDS form.
- Documentation: Ensure that the MDS form is consistent with her medical records and includes all supporting documentation.
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Illustration:
- Provide a sample MDS form showing item set F0800J coded as “0” (No) with the corresponding supporting documentation.
Please note that the information provided in this guide for MDS 3.0 Item set F0800J 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.
