V0100F: Prior Assessment PHQ Staff: Total Mood Score, Step-by-Step
Step-by-Step Coding Guide for Item Set V0100F: "Prior Assessment PHQ Staff: Total Mood Score"
1. Review of Medical Records
- Objective: Ensure accurate and comprehensive documentation of the resident’s prior assessment of mood using the PHQ (Patient Health Questionnaire) conducted by staff.
- Actions:
- Access the most recent and prior MDS assessments, focusing on Section D (Mood) to review the PHQ-9 or PHQ-9-OV (Observation Version) scores recorded by staff.
- Confirm that all relevant mood assessments, including the PHQ staff assessments, are properly documented and accessible.
- Review any related documentation that supports the staff’s assessment of the resident's mood, such as notes from interdisciplinary team meetings, care plans, and mental health evaluations.
2. Understanding Definitions
- V0100F: Prior Assessment PHQ Staff - Total Mood Score: This item records the total mood score from the PHQ-9 or PHQ-9-OV completed by staff during the prior assessment. This score provides a quantifiable measure of depressive symptoms as observed by the staff.
- PHQ-9/PHQ-9-OV: These are standardized tools used to assess the severity of depression based on responses to nine specific questions related to mood and behavior over the past two weeks .
3. Coding Instructions
- Step-by-Step:
- Step 1: Identify the prior assessment where the PHQ-9 or PHQ-9-OV was completed by staff.
- Step 2: Locate the total mood score from the prior PHQ assessment. This score will be a sum of the values assigned to each of the nine items in the PHQ-9 or PHQ-9-OV.
- Step 3: Enter the total mood score from the prior assessment into the V0100F field.
- Step 4: If no prior PHQ assessment was completed by staff, enter "00" to indicate that no score is available from the previous assessment.
4. Coding Tips
- Consistency: Ensure that the score entered in V0100F accurately reflects the total mood score from the prior PHQ-9 or PHQ-9-OV assessment.
- Verification: Double-check the prior MDS assessment to confirm the accuracy of the score recorded.
- Document Absence: If no PHQ-9 or PHQ-9-OV was conducted by staff in the prior assessment, clearly document the reason in the resident’s records.
5. Documentation
- Objective: Maintain a clear record of the resident’s prior mood assessments to support ongoing care planning and monitoring.
- Actions:
- Document any changes in the resident’s mood or behavior that may have influenced the PHQ score over time.
- Ensure that the resident’s current care plan reflects the findings from both the current and prior mood assessments.
- Keep a record of any discussions or interventions that resulted from the mood assessments.
6. Common Errors to Avoid
- Incorrect Scores: Entering an incorrect total mood score from the prior assessment can lead to inaccurate care planning and potential regulatory issues.
- Failure to Document: Not documenting the absence of a prior PHQ assessment when applicable can result in incomplete records and misunderstandings during care planning.
- Overlooking Prior Assessments: Ensure that you review the correct prior assessment, especially if there have been multiple assessments close in time.
7. Practical Application
- Example 1: A resident previously scored 12 on the PHQ-9, indicating moderate depression. This score is entered in V0100F to reflect the prior assessment’s findings. The care team uses this information to track the resident’s mood over time and adjust the care plan accordingly.
- Example 2: In a previous assessment, the staff did not complete the PHQ-9 due to the resident's refusal to participate. V0100F is coded as "00," and the care team documents the reason for the absence of a prior mood score.
Please note that the information provided in this guide for MDS 3.0 Item set V0100F 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.
