MDS Alert

Published on Fri Oct 15, 2010 PDF

Example No. 1: "Mrs. W. has diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure. She is on 2 liters of oxygen and daily respiratory treatments. With oxygen she is able to ambulate and participate in most group activities. She reports feeling 'winded' when going on outings that require walking one or more blocks and has been observed having to stop to rest several times under such circumstances. Recently, she describes feeling 'out of breath' when she tries to lie down."

Example No. 2: " Mr. T. has used an inhaler for years. He is not typically noted to be short of breath. Three days ago, during a respiratory illness, he had mild trouble with his breathing, even when sitting in bed. His shortness of breath also caused him to limit group activities."

1. Check J1100A: if shortness of breath or trouble breathing is present when the resident is engaging in activity. Shortness of breath could be present during activity as limited as turning or moving in bed during daily care or with more strenuous activity such as transferring, walking, or bathing. If the resident avoids activity or is unable to engage in activity because of shortness of breath, then code this as present.

2. Check J1100B: if shortness of breath or trouble breathing is present when the resident is sitting at rest.

3. Check J1100C: if shortness of breath or trouble breathing is present when the resident attempts to lie flat. Also code this as present if the resident avoids lying flat because of shortness of breath.

4. Check J1100Z: if the resident reports no shortness of breath or trouble breathing and the medical record and staff interviews indicate that shortness of breath appears to be absent or well controlled with current medication."