RAI Manual v1.20.1Steps for Assessment
1. Interview any resident when D0100 = 1.
2. Conduct the interview in a private setting.
3. If an interpreter is used during resident interviews, the interpreter should not attempt to
determine the intent behind what is being translated, the outcome of the interview, or the
meaning or significance of the resident’s responses.
4. Sit so that the resident can see your face. Minimize glare by directing light sources away
from the resident’s face.
5. Be sure the resident can hear you.
•
Residents with a hearing impairment should be interviewed using their usual
communication devices/techniques, as applicable, during the interview.
•
Try an external assistive device (headphones or hearing amplifier) if you have any doubt
about hearing ability.
•
Minimize background noise.
6. If you are administering the PHQ-2 to 9© in paper form, be sure that the resident can see the
print. Provide large print or assistive device (e.g., page magnifier) if necessary.
7. Explain the reason for the interview before beginning.
DEFINITION
PATIENT HEALTH
QUESTIONNAIRE
(PHQ-2 to 9©)
A validated interview that
screens for symptoms of
depression. It provides a
standardized severity score
and a rating for evidence of a
depressive disorder.
D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
Suggested language: “I am going to ask you some questions about your mood and
feelings over the past 2 weeks. I will also ask about some common problems that are
known to go along with feeling down. Some of the questions might seem personal, but
everyone is asked to answer them. This will help us provide you with better care.”
8. Explain and /or show the interview response choices. A cue card with the response choices
clearly written in large print might help the resident comprehend the response choices.
Suggested language: “I am going to ask you how often you have been bothered by a
particular problem over the last 2 weeks. I will give you the choices that you see on this
card.” (Say while pointing to cue card): “0-1 days—never or 1 day, 2-6 days—several
days, 7-11 days—half or more of the days, or 12-14 days—nearly every day.”
9. Ask the first two questions of the Resident Mood Interview (PHQ-2 to 9©).
Suggested language: “Over the last 2 weeks, have you been bothered by any of the
following problems?”
For each of the questions:
•
Read the item as it is written.
•
Do not provide definitions because the meaning must be based on the resident’s
interpretation. For example, the resident defines for themself what “tired” means; the item
should be scored based on the resident’s interpretation.
•
Each question must be asked in sequence to assess Symptom Presence (column 1) and
Symptom Frequency (column 2) before proceeding to the next question.
•
Enter code 9 in Column 1 and leave Column 2 blank if the resident was unable or chose
not to complete the assessment or responded nonsensically. A nonsensical response is one
that is unrelated, incomprehensible, or incoherent or if the resident’s response is not
informative with respect to the item being rated (e.g., when asked the question about
“poor appetite or overeating,” the resident answers, “I always win at poker.”).
•
For a yes response, ask the resident to tell you how often they were bothered by the
symptom over the last 2 weeks. Use the response choices in D0150 Column 2, Symptom
Frequency. Start by asking the resident the number of days that they were bothered by the
symptom and read and show cue card with frequency categories/descriptions (0-1 days—
never or 1 day, 2-6 days—several days, 7-11 days—half or more of the days, or 12-14
days—nearly every day).
10. Determine whether to ask the remaining seven questions (D0150C to D0150I) of the
Resident Mood Interview (PHQ-2 to 9©). Whether or not further evaluation of a resident’s
mood is needed depends on the resident’s responses to the first two questions (D0150A and
D0150B) of the Resident Mood Interview.
•
If both D0150A1 and D0150B1 are coded 9, OR both D0150A2 and D0150B2 are coded
0 or 1, end the PHQ interview; otherwise continue.
— If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank,
then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700,
Social Isolation.
— If both D0150A2 and D0150B2 are coded 0 or 1, then end the PHQ-2© and enter the
total score from D0150A2 and D0150B2 in D0160, Total Severity Score.
D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
•
For all other scenarios, proceed to ask the remaining seven questions (D0150C to D0150I
of the PHQ-9©) and complete D0160, Total Severity Score.
Manual page D-3RAI Manual v1.20.1Coding Instructions
for Column 1. Symptom Presence
•
Code 0, no: if resident indicates symptoms listed are not present. Enter 0 in Column 2
as well.
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Code 1, yes: if resident indicates symptoms listed are present. Enter 0, 1, 2, or 3 in
Column 2, Symptom Frequency.
•
Code 9, no response: if the resident was unable or chose not to complete the
assessment or responded nonsensically. Leave Column 2, Symptom Frequency, blank.
•
Enter a Dash in Column 1 if the symptom presence was not assessed.
Coding Instructions for Column 2. Symptom Frequency
Record the resident’s responses as they are stated, regardless of whether the resident or the
assessor attributes the symptom to something other than mood. Further evaluation of the clinical
relevance of reported symptoms should be explored by the responsible clinician.
•
Code 0, never or 1 day: if the resident indicates that during the past 2 weeks they
have never been bothered by the symptom or have only been bothered by the symptom on
1 day.
•
Code 1, 2-6 days (several days): if the resident indicates that during the past 2
weeks they have been bothered by the symptom for 2-6 days.
•
Code 2, 7-11 days (half or more of the days): if the resident indicates during the
past 2 weeks they have been bothered by the symptom for 7-11 days.
•
Code 3, 12-14 days (nearly every day): if the resident indicates during the past 2
weeks they have been bothered by the symptom for 12-14 days.
Manual page D-3RAI Manual v1.20.1Coding Tips
and Special Populations
•
Attempt to conduct the interview with ALL residents.
•
If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then
end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social
Isolation.
•
If Column 1 equals 0, enter 0 in Column 2.
•
If Column 1 equals 9 or dash, leave Column 2 blank.
•
For question D0150I, Thoughts That You Would Be Better Off Dead or of Hurting
Yourself in Some Way:
— Beginning interviewers may feel uncomfortable asking this item because they may
fear upsetting the resident or may feel that the question is too personal. Others may
worry that it will give the resident inappropriate ideas. However,
○ Experienced interviewers have found that most residents who are having this
feeling appreciate the opportunity to express it.
D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
○ Asking about thoughts of self-harm does not give the person the idea. It does let
the provider better understand what the resident is already feeling.
○ The best interviewing approach is to ask the question openly and without
hesitation.
•
If the resident uses their own words to describe a symptom, this should be briefly
explored. If you determine that the resident is reporting the intended symptom but using
their own words, ask them to tell you how often they were bothered by that symptom.
•
Select only one frequency response per item.
•
If the resident has difficulty selecting between two frequency responses, code for the
higher frequency.
•
Some items (e.g., item D0150F) contain more than one phrase. If a resident gives
different frequencies for the different parts of a single item, select the highest frequency
as the score for that item.
•
In the rare situation that the resident cannot provide a frequency, following a yes
response to a symptom in Column 1, enter a dash in Column 2. CMS expects a dash
response to be rare.
•
Residents may respond to questions:
— verbally,
— by pointing to their answers on the cue card, OR
— by writing out their answers.
Interviewing Tips and Techniques
•
Repeat a question if you think that it has been misunderstood or misinterpreted.
•
Some residents may be eager to talk with you and will stray from the topic at hand. When
a person strays, you should gently guide the conversation back to the topic.
— Example: Say, “That’s interesting, now I need to know…”; “Let’s get back to…”; “I
understand, can you tell me about….”
•
Validate your understanding of what the resident is saying by asking for
clarification.
— Example: Say, “I think I hear you saying that…”; “Let’s see if I understood you
correctly.”; “You said…. Is that right?”
•
If the resident has difficulty selecting a frequency response, start by offering a single
frequency response and follow with a sequence of more specific questions. This is known
as unfolding.
— Example: Say, “Would you say [name symptom] bothered you more than half the
days in the past 2 weeks?”
○ If the resident says “yes,” show the cue card and ask whether it bothered them
nearly every day (12-14 days) or on half or more of the days (7-11 days).
○ If the resident says “no,” show the cue card and ask whether it bothered them
several days (2-6 days) or never or 1 day (0-1 day).
D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
•
Noncommittal responses such as “not really” should be explored. Residents may be
reluctant to report symptoms and should be gently encouraged to tell you if the symptom
bothered them, even if it was only some of the time. This is known as probing. Probe by
asking neutral or nondirective questions such as:
— “What do you mean?”
— “Tell me what you have in mind.”
— “Tell me more about that.”
— “Please be more specific.”
— “Give me an example.”
•
Sometimes respondents give a long answer to interview items. To narrow the answer to
the response choices available, it can be useful to summarize their longer answer and then
ask them which response option best applies. This is known as echoing.
— Example: Item D0150E, Poor Appetite or Overeating. The resident responds “the
food is always cold and it just doesn’t taste like it does at home. The doctor won’t let
me have any salt.”
○ Possible interviewer response: “You’re telling me the food isn'tisn'tisn'tisn'tisn't what you eat at
home and you can’t add salt. How often would you say that you were bothered by
poor appetite or over-eating during the last 2 weeks?”
— Example: Item D0150A, Little Interest or Pleasure in Doing Things. The resident,
when asked how often they have been bothered by little interest or pleasure in doing
things, responds, “There’s nothing to do here, all you do is eat, bathe, and sleep. They
don’t do anything I like to do.”
○ Possible interview response: “You’re saying thereisn'tt much to do here and I
want to come back later to talk about some things you like to do. Thinking about
how you’ve been feeling over the past 2 weeks, how often have you been bothered
by little interest or pleasure in doing things.”
— Example: Item D0150B, Feeling Down, Depressed, or Hopeless. The resident,
when asked how often they have been bothered by feeling down, depressed, or
hopeless, responds: “How would you feel if you were here?”
○ Possible interview response: “You asked how I would feel, but it is important that
I understand your feelings right now. How often would you say that you have
been bothered by feeling down, depressed, or hopeless during the last 2 weeks?”
D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
•
If the resident has difficulty with longer items, separate the item into shorter parts, and
provide a chance to respond after each part. This method, known as disentangling, is
helpful if a resident has moderate cognitive impairment but can respond to simple, direct
questions.
— Example: Item D0150E, Poor Appetite or Overeating.
○ You can simplify this item by asking: “In the last 2 weeks, how often have you
been bothered by poor appetite?” (pause for a response) “Or overeating?”
— Example: Item D0150C, Trouble Falling or Staying Asleep, or Sleeping Too
Much.
○ You can break the item down as follows: “How often are you having problems
falling asleep?” (pause for response) “How often are you having problems staying
asleep?” (pause for response) “How often do you feel you are sleeping too
much?”
— Example: Item D0150H, Moving or Speaking So Slowly That Other People Could
Have Noticed. Or the Opposite—Being So Fidgety or Restless That You Have
Been Moving Around a Lot More than Usual.
○ You can simplify this item by asking: “How often are you having problems with
moving or speaking so slowly that other people could have noticed?” (pause for
response) “How often have you felt so fidgety or restless that you move around a
lot more than usual?”
Manual page D-3