J1100B: Short Breath/Trouble Breathing: Sitting at Rest, Step-by-Step

Step-by-Step Coding Guide for Item Set J1100B: Short Breath/Trouble Breathing: Sitting at Rest

1. Review of Medical Records

• Objective: Identify any instances or documentation related to the resident experiencing shortness of breath or trouble breathing while sitting at rest.
• Steps:
  1. Gather Records: Collect the resident’s medical records, including admission notes, nursing notes, progress notes, and previous assessments.
  2. Review History: Look for any documented history of respiratory issues, chronic obstructive pulmonary disease (COPD), asthma, or other related conditions.
  3. Examine Current Notes: Review recent nursing notes and daily logs for any observations or reports of the resident experiencing shortness of breath or trouble breathing while at rest.

2. Understanding Definitions

• Short Breath/Trouble Breathing: Difficulty in breathing or shortness of breath that occurs without exertion, specifically while the resident is sitting and at rest.
• Assessment Item J1100B: An MDS item that records whether the resident experiences shortness of breath or trouble breathing while sitting at rest.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set J1100B on the MDS form.
  2. Direct Inquiry: Ask the resident if they have experienced shortness of breath or trouble breathing while sitting at rest.
  3. Review Documentation: Cross-check the resident’s response with medical records, particularly recent nursing notes and daily logs.
  4. Record Response: Based on the resident’s response and documentation:
     • Code 0 if the resident did not experience shortness of breath/trouble breathing while sitting at rest.
     • Code 1 if the resident did experience shortness of breath/trouble breathing while sitting at rest.
  5. Verify and Validate: Ensure that the information is consistent with documented observations and the resident’s condition.

4. Coding Tips

• Resident’s Input: Always prioritize the resident’s input when they are capable of providing reliable information.
• Cross-Verification: Use multiple sources (e.g., family members, staff observations) to verify the resident’s experiences.
• Consistency: Ensure consistency in documentation and coding across all sections of the MDS form.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set J1100B indicating the presence or absence of shortness of breath/trouble breathing while sitting at rest.
  • Medical Records: Admission notes, progress notes, and any relevant documentation that provides information about the resident’s respiratory status.
  • Verification Notes: Notes confirming the resident’s condition and any observations by nursing staff or caregivers.

6. Common Errors to Avoid

• Assumptions: Avoid making assumptions based on the resident’s medical history without current verification.
• Incomplete Information: Ensure that all sources of information are reviewed and cross-verified.
• Inconsistent Entries: Avoid discrepancies between the resident’s reported experiences and documented observations.

7. Practical Application

• Example:
  • Resident Background: Ms. Jane Smith, a resident with a history of COPD, is being assessed.
  • Review Process: Access Ms. Smith’s medical records, including recent nursing notes and daily logs.
  • Direct Inquiry: Ask Ms. Smith, “Have you experienced shortness of breath or trouble breathing while sitting at rest?”
  • Coding Process:
    • Step 1: Locate item set J1100B on the MDS form.
    • Step 2: Ms. Smith responds that she has experienced shortness of breath while sitting at rest.
    • Step 3: Verify with nursing notes which indicate similar observations.
    • Step 4: Enter 1 indicating that Ms. Smith did experience shortness of breath/trouble breathing while sitting at rest.
  • Illustration:
    • Provide a sample MDS form showing item set J1100B with “1” entered.
    • Include an example of a nursing note confirming the observation.

Please note that the information provided in this guide for MDS 3.0 Item set J1100B 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.