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Understanding and Coding MDS 3.0 Item I6100: Post-Traumatic Stress Disorder (PTSD)

Section I. Active Diagnoses

Understanding and Coding MDS 3.0 Item I6100: Post-Traumatic Stress Disorder (PTSD)

Introduction

Purpose:
Post-traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a traumatic event. Residents with PTSD may experience symptoms such as flashbacks, nightmares, and severe anxiety. MDS Item I6100 ensures that residents diagnosed with PTSD receive appropriate mental health care, including therapy and medication, to manage their symptoms and improve their quality of life.

What is MDS Item I6100?

Explanation:
MDS Item I6100 records the presence of PTSD in residents. Accurate documentation of PTSD allows for the development of comprehensive care plans that address the mental, emotional, and behavioral symptoms associated with the disorder. This item supports the integration of mental health interventions such as psychotherapy, trauma-informed care, and pharmacological treatments into the resident's overall care.

Guidelines for Coding MDS Item I6100

Coding Instructions:

  • PTSD must be diagnosed by a healthcare provider and actively managed during the look-back period.
  • Code this item as present if the resident is receiving any treatment for PTSD, including therapy or medication.
    For example, if a resident is receiving counseling for trauma and prescribed medication to manage anxiety related to PTSD, MDS Item I6100 should be coded as present.

Best Practices for Accurate Coding

Documentation:

  • Ensure that the medical record includes a documented diagnosis of PTSD along with any ongoing treatments, such as therapy sessions or medications.

Communication:

  • Collaborate with mental health professionals, nursing staff, and social workers to ensure that the care plan addresses the resident’s trauma history and PTSD symptoms. Regular updates and interdisciplinary communication are crucial for managing PTSD effectively.

Training:

  • Train staff on trauma-informed care principles, including how to interact with residents in a way that avoids triggering PTSD symptoms and helps them feel safe and supported.

Conclusion

Summary:
Accurately coding MDS Item I6100 ensures that residents with PTSD receive the mental health care they need to manage their symptoms and improve their emotional well-being.

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

Reference

  • CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Pages I-14 to I-15​.

Disclaimer

This guide for MDS 3.0 Item I6100 is 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 this guide as necessary.

Tags
MDS 3.0
PTSD
Post-Traumatic Stress Disorder
trauma-informed care
MDS Coding
I6100
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Section I. Active Diagnoses

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