Understanding and Coding MDS 3.0 Item C0900A: Staff Assessment of Mental Status - Recall Current Season

Understanding and Coding MDS 3.0 Item C0900A: Staff Assessment of Mental Status - Recall Current Season

Introduction

Purpose:
MDS 3.0 Item C0900A is a vital component of assessing a resident’s cognitive function in long-term care facilities, specifically focusing on their orientation to time. This item evaluates whether a resident can accurately recall the current season, which is an indicator of their cognitive awareness and memory. Accurate coding of this item helps identify residents who may be experiencing cognitive decline or disorientation, allowing for the development of targeted care plans to support their cognitive health.

What is MDS Item C0900A?

Explanation:
MDS Item C0900A, "Staff Assessment of Mental Status: Recall Current Season," is part of Section C, which addresses cognitive patterns. This item assesses a resident’s ability to correctly identify the current season. The resident’s ability to recall the correct season is an important indicator of their temporal orientation, which is crucial for understanding their overall cognitive function. Temporal disorientation, such as not knowing the current season, can be a sign of cognitive impairment, such as dementia or delirium.

Staff conduct this assessment based on observations and interactions with the resident, particularly when the resident is unable to participate in the Brief Interview for Mental Status (BIMS).

Guidelines for Coding C0900A

Coding Instructions:
When coding Item C0900A, staff should determine whether the resident can correctly recall the current season. The coding options reflect the resident’s ability to accurately identify the season.

1. Code 0 - Incorrect: The resident is unable to recall the current season or gives an incorrect response.
2. Code 1 - Correct: The resident correctly identifies the current season (e.g., spring, summer, fall, winter).

Example Scenario:
Mr. Thompson is asked by a staff member, “What season is it right now?” Mr. Thompson responds, “It’s winter,” when the current season is indeed winter. In this case, Item C0900A should be coded as "1 - Correct" because Mr. Thompson accurately recalled the current season.

However, if Mrs. Davis responds, “It’s spring,” when the current season is actually autumn, Item C0900A should be coded as "0 - Incorrect," indicating a problem with her temporal orientation.

Best Practices for Accurate Coding

Documentation:

• Detailed Observations: Record the resident’s response when asked about the current season, noting whether the answer was correct or incorrect. This documentation provides a clear record of the resident’s cognitive abilities related to temporal orientation.
• Consistency: Ensure that assessments are conducted regularly to monitor any changes in the resident’s ability to recall the current season, which can indicate shifts in cognitive function.
• Objective Evidence: Support coding decisions with documented interactions that clearly demonstrate the resident’s orientation to time.

Communication:

• Interdisciplinary Team: Share findings regarding the resident’s ability to recall the current season with the interdisciplinary care team. This information is vital for developing comprehensive care plans that address cognitive deficits.
• Family Involvement: Engage the resident’s family in discussions about the resident’s cognitive status, as their insights can help validate the staff’s observations and inform care strategies.

Training:

• Staff Education: Train staff to assess temporal orientation accurately by recognizing the specific indicators of intact or impaired awareness of the current season.
• Assessment Techniques: Provide training on effective assessment techniques, including how to interact with residents who may have varying levels of cognitive function or communication barriers.
• Updates and Refresher Courses: Regularly update staff on any changes to MDS guidelines and offer refresher courses to maintain high standards in cognitive assessments.

Conclusion

Summary:
Accurately coding MDS Item C0900A is essential for assessing a resident’s temporal orientation through their ability to recall the current season. This evaluation is crucial for understanding the resident’s cognitive health and for creating care plans that support their mental well-being. By adhering to the coding guidelines and best practices, healthcare professionals can ensure comprehensive and accurate cognitive assessments, leading to improved care outcomes for residents in long-term care settings.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference

Please refer to CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, specifically Chapter 3, Page C-9, for detailed instructions on coding Item C0900A.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item C0900A: Staff Assessment of Mental Status - Recall Current Season was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.