F0800R: Staff Assessment - Spend Time Away from a Nursing Home, Step-by-Step
Step-by-Step Coding Guide for Item Set F0800R: Staff Assessment - Spend Time Away from a Nursing Home
1. Review of Medical Records
- Objective: To determine if the resident spends time away from the nursing home.
- Process:
- Care Plans: Examine the resident's care plan for any scheduled time away from the facility, such as family visits, outings, or medical appointments.
- Nursing Notes: Review nursing and caregiver notes for documented instances when the resident spent time outside the nursing home.
- Activity Logs: Check activity and outing logs maintained by the facility’s activity department or social services.
2. Understanding Definitions
- Spend Time Away from Nursing Home: This refers to any period during which the resident leaves the nursing home, whether for medical appointments, family visits, day trips, or other activities that take place outside the facility.
3. Coding Instructions
- Code F0800R:
- 0: No, the resident does not spend time away from the nursing home.
- 1: Yes, the resident spends time away from the nursing home.
- Example: If the resident goes on a family outing or attends regular medical appointments outside the facility, code F0800R as '1'.
4. Coding Tips
- Verify Frequency: Ensure that the time away is part of a regular routine or occurs frequently enough to be significant.
- Consult Multiple Sources: Use information from various documentation sources to confirm that the resident spends time away from the facility.
5. Documentation
- Required Documentation:
- Care Plan Entries: Documentation that outlines planned outings or appointments.
- Activity Logs: Records of the dates and times the resident left and returned to the facility.
- Nursing and Social Work Notes: Detailed notes about the reasons for and duration of time spent away.
- Example: "On 05/10/2024, the resident was taken out by family members for a day trip to the park. They left at 10 AM and returned at 4 PM. The outing was documented in the activity log and noted in the care plan."
6. Common Errors to Avoid
- Inconsistent Documentation: Failing to consistently document all instances of the resident spending time away from the facility.
- Overlooking Short Trips: Not recording short trips or regular outings, such as weekly medical appointments.
- Misclassification: Confusing time away with time spent in common areas of the facility.
7. Practical Application
- Scenario: A resident regularly visits their family every Sunday afternoon. The visits are documented in the care plan, and each outing is recorded in the activity log and nursing notes. Staff ensure the resident’s safe departure and return, noting any observations or changes in the resident’s condition post-visit. Based on this thorough documentation and regular occurrences, F0800R is coded as '1'.
Please note that the information provided in this guide for MDS 3.0 Item set F0800R 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.
