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Manual page E-1DiraChart MDS item reference
E0100ASection Ev1.20.1Manual page E-1
Psychosis: hallucinations
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 coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Check all that apply
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Not checked
Condition does not apply under the item instruction.
Manual page E-1Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
1. Review the resident’s medical record for the 7-day look-back period.
2. Interview staff members and others who have had the opportunity to observe the resident in a
variety of situations during the 7-day look-back period.
3. Observe the resident during conversations and the structured interviews in other assessment
sections and listen for statements indicating an experience of hallucinations, or the
expression of false beliefs (delusions).
4. Clarify potentially false beliefs:
•
When a resident expresses a belief that is plausible but alleged by others to be false (e.g.,
history indicates that the resident’s spouse died 20 years ago, but the resident states their
spouse has been visiting them every day), try to verify the facts to determine whether
there is reason to believe that it could have happened or whether it is likely that the belief
is false.
•
When a resident expresses a clearly false belief, determine if it can be readily corrected
by a simple explanation of verifiable (real) facts (which may only require a simple
reminder or reorientation) or demonstration of evidence to the contrary. Do not, however,
challenge the resident.
•
The resident’s response to the offering of a potential alternative explanation is often
helpful in determining whether the false belief is held strongly enough to be considered
fixed.
Coding Instructions
Code based on behaviors observed and/or thoughts expressed in the last 7 days rather than the
presence of a medical diagnosis. Check all that apply.
•
Check E0100A, hallucinations: if hallucinations were present in the last 7 days. A
hallucination is the perception of the presence of something that is not actually there. It
may be auditory or visual or involve smells, tastes or touch.
•
Check E0100B, delusions: if delusions were present in the last 7 days. A delusion
is a fixed, false belief not shared by others that the resident holds true even in the face of
evidence to the contrary.
•
Check E0100Z, none of the above: if no hallucinations or delusions were present
in the last 7 days.
E0100: Potential Indicators of Psychosis (cont.)
Coding Tips
and Special Populations
•
If a belief cannot be objectively shown to be false, or it is not possible to determine
whether it is false, do not code it as a delusion.
•
If a resident expresses a false belief but easily accepts a reasonable alternative
explanation, do not code it as a delusion. If the resident continues to insist that the belief
is correct despite an explanation or direct evidence to the contrary, code as a delusion.
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