Understanding and Coding MDS 3.0 Item C0400A: BIMS Resident Interview - Able to Recall "Sock"

Understanding and Coding MDS 3.0 Item C0400A: BIMS Resident Interview - Able to Recall "Sock"

Introduction

Purpose:
The Brief Interview for Mental Status (BIMS) is a key component of cognitive assessment in long-term care settings. MDS 3.0 Item C0400A focuses on the resident’s ability to recall the word "sock" during the BIMS interview. This task evaluates short-term memory, a critical aspect of cognitive function. Accurate coding of this item helps identify potential memory impairments, which are essential for developing appropriate care plans and interventions to enhance the resident’s quality of life.

What is MDS Item C0400A?

Explanation:
MDS Item C0400A, "BIMS Resident Interview: Able to Recall 'Sock'," is part of Section C, which addresses cognitive patterns. This item specifically assesses whether the resident can remember the word "sock" after a brief delay, following the initial repetition task in the BIMS interview. The ability to recall this word is an important indicator of the resident’s short-term memory, which is crucial for daily functioning and decision-making.

During the BIMS, residents are initially asked to repeat three words—"sock," "blue," and "bed." Later, they are asked to recall these words without prompts. Item C0400A evaluates the resident’s ability to recall "sock" independently, contributing to the overall BIMS score and providing insight into the resident’s cognitive status.

Guidelines for Coding C0400A

Coding Instructions:
When coding Item C0400A, the interviewer should ask the resident to recall the three words ("sock," "blue," "bed") that were mentioned earlier in the interview. The coding for C0400A specifically reflects whether the resident can correctly recall the word "sock."

1. Code 0 - No: The resident is unable to recall the word "sock."
2. Code 1 - Yes, after cueing ("something to wear"): The resident recalls the word "sock" only after being provided with a cue or prompt, such as "something to wear."
3. Code 2 - Yes, no cue required: The resident recalls the word "sock" without any cues or prompts.

Example Scenario:
During the BIMS interview, the interviewer asks Mrs. Jones, “What were the three words I asked you to remember?” Mrs. Jones correctly recalls "sock" without needing any hints. In this case, Mrs. Jones should be coded as "2 - Yes, no cue required" for Item C0400A because she remembered the word "sock" independently.

Best Practices for Accurate Coding

Documentation:
Document the resident’s response to the recall task, noting whether they remembered the word "sock" independently or required a cue. This documentation is important for tracking changes in the resident’s memory over time and ensuring consistency in future assessments.

Communication:
Share the results of the BIMS, including the resident’s ability to recall "sock," with the interdisciplinary care team. This information is crucial for developing care plans that address any memory impairments and support the resident’s cognitive health.

Training:
Ensure that staff conducting the BIMS are trained to deliver the recall task clearly and to wait patiently for the resident’s response. Training should also cover how to provide cues appropriately if the resident struggles to recall the word, ensuring that the resident feels supported during the interview.

Conclusion

Summary:
Accurately coding MDS Item C0400A is essential for assessing a resident’s short-term memory as part of the BIMS. This assessment helps identify cognitive impairments that may affect the resident’s ability to engage in daily activities and make decisions about their care. By following the coding guidelines and best practices, healthcare professionals can ensure that the cognitive assessment is conducted accurately, leading to better care outcomes for residents.

Click here to obtain 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-5, for detailed instructions on coding Item C0400A.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item set C0400A: BIMS Resident Interview - Able to Recall "Sock" 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.