DiraChart MDS item reference
C1310CSection Cv1.20.1Manual page C-29
Signs of delirium: disorganized thinking
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick codingAnswer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
Delirium
C1310. Signs and Symptoms of Delirium (from CAM®)
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record
EnterCode A. Acute Onset Mental Status Change
[ ] Is there evidence of an acute change in mental status from the resident’s baseline?
0. No
1. Yes
0. Behavior not present [ ] B. Inattention - Did the resident have difficulty focusing attention, for example, being
. . easily distractible or having difficulty keeping track of what was being said?
1. Behavior continuously present, does
not fluctuate [ ] C. Disorganized Thinking - Was the resident’s thinking disorganized or incoherent
2. Behavior present, fluctuates (comes and (rambling or irrelevant conversation, unclear or togical flow of ideas, or
goes, changes in severity) unpredictable switching from subject to subject)?
[ ] D. Altered Level of Consciousness - Did the resident have altered level of
consciousness, as indicated by any of the following criteria?
= vigilant - startled easily to any sound or touch
= lethargic - repeatedly dozed off when being asked questions, but responded to
voice or touch
= stuporous - very difficult to arouse and keep aroused for the interview
= comatose - could not be aroused
Item-specific instructionsCoding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
RAI Manual v1.20.1Steps for Assessment
1. Observe resident behavior during the BIMS items (C0200–
C0400) for the signs and symptoms of delirium. Some
experts suggest that increasing the frequency of assessment
(as often as daily for new admissions) will improve the
level of detection.
2. If the Staff Assessment for Mental Status items (C0700–
C1000) were completed instead of the BIMS, ask staff
members who conducted the interview about their
observations of signs and symptoms of delirium.
3. Review medical record documentation during the 7-day look-back period to determine the
resident’s baseline status, fluctuations in behavior, and behaviors that might have occurred
during the 7-day look-back period that were not observed during the BIMS.
4. Observe the resident’s behavior during interactions and consult with other staff, family
members/caregivers, and others in a position to observe the resident’s behavior during the 7-
day look-back period.
Additional guidance on the signs and symptoms of delirium can be found in Appendix C.
Manual page C-29RAI Manual v1.20.1Coding Instructions
for C1310A, Acute Mental Status Change
•
Code 0, no: if there is no evidence of acute mental status change from the resident’s
baseline.
•
Code 1, yes: if resident has an alteration in mental status observed in the observation
period that represents an acute change from baseline.
Manual page C-29RAI Manual v1.20.1Coding Tips
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Manual page C-29 MDS item matrixAssessment Applicability
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