Sections D - E - GG

Section D: Mood

D0150 Resident Mood Interview (PHQ-2 to 9©) 

• Supportive documentation withing the record; nurse’s notes, physician’s notes, therapy notes, consultation notes from specialists

D0160 Total Severity Score

D0500 Staff Assessment of Resident Mood (PHQ-9-OV*)

• Is only conducted if unable to complete the above mood assessment (D0150)
• Supportive documentation would include nurses/physician’s notes, therapy notes, other staff documentation

D0600 Total Severity Score

Section E: Behavior

E0100 Potential Indicators of Psychosis

• Within the seven-day look back period were any indicators present
• Supportive documentation: nurses/physicians notes, psychiatrist consult if present, therapy notes. medication administration record (MAR), treatment administration record (TAR), activities of daily living (ADL)

E0200 Behavioral Symptom - Presence & Frequency

E0800 Rejection of Care - Presence & Frequency

E0900 Wandering - Presence & Frequency

Section GG: Functional Abilities and Goals

GG0130 Self-Care (Assessment period is the first 3 days of the Stay)

• Supportive documentation from nurse’s notes, therapy notes, ADL, physician notes

GG0170 Mobility (Assessment period is the first 3 days of the stay)

• Supportive documentation from nurse’s notes, therapy notes, ADL, physician notes