HOPE Guidance Manual v1.02, Item J2030

Timepoint(s) Item Completed

Admission (ADM)

Item-Specific Instructions

• Assess the patient for the presence of shortness of breath.

• Item completion should be based on what is determined during the assessment visit and/or included in

the clinical record. Do not use sources external to the clinical record.

• Review the clinical record for documentation of screening for shortness of breath.

• A screening for shortness of breath must include evaluating the patient for presence/absence of shortness

of breath and, if shortness of breath is present, rating its severity.

• Review all response choices before making a selection.

A. Was the patient screened for shortness of breath?

• Code 0, No, if the patient was not screened for shortness of breath, and/or there is no documentation

that indicates the patient was screened for shortness of breath. Skip to Item J2050, Symptom Impact

Screening.

• Code 1, Yes, if the patient was screened for shortness of breath or there is documentation that

indicates the patient was screened for shortness of breath.

B. Date of first screening for shortness of breath

• Enter the date of the first screening for shortness of breath.

• It is possible that at the time of completion, multiple screenings for shortness of breath will be

documented in the clinical record.

• Complete shortness of breath screening items based on the first shortness of breath screening

documented in the clinical record.

C. Did the screening indicate the patient had shortness of breath?

• Code 0, No, if the screening indicated that the patient did not have shortness of breath. Skip to Item

J2050, Symptom Impact Screening.

o Use code 0, if the documentation indicates the presence of shortness but there is no documentation

of severity.

• Code 1, Yes, if the screening indicated that the patient had shortness of breath.

Coding Tips

• Consider whether shortness of breath is an active problem at the time of the screening.

o Indicators of shortness of breath as an active problem include, but are not limited to:

 Patient’s self-report or caregiver report of distress or “trouble breathing” from shortness of

breath or dyspnea.

 Documentation of dyspnea or shortness of breath at rest, upon exertion or other times.

 Observed clinical signs of shortness of breath.

• On the basis of reports of recent symptoms, current treatment, and patient/family history, the assessing

clinician may determine that shortness of breath is an active problem, even if shortness of breath does

not occur during the assessment visit.

• There may be situations where an order for Oxygen as needed (PRN) exists, but the assessing clinician

does not determine shortness of breath to be an active problem for the patient at the time of the

screening.

o In this situation, the skip pattern is maintained for J2030C to skip J2040, and the oxygen would not

be reported as a treatment for J2040.

Examples

1. During the initial nursing visit, on 11-15-2025 the patient is very drowsy, but appears comfortable. The

nurse does not ask about shortness of breath during the visit.”

Coding: J2030A: Was the patient screened for shortness of breath? would be coded 0, No and skip to

Item J2050, Symptom Impact Screening.

Rationale: The nurse does not screen for shortness of breath and the documentation provides no

evidence that the patient was screened for shortness of breath. Thus, code 0, No for J2030A and skip to

Item J2050.

2. The clinical note dated 11-12-2025 shows the patient reports no discomfort and is breathing shallowly

without signs of distress. There are no concerns about breathing from the patient or family.

Coding: J2030A: Was the patient screened for shortness of breath? Code 1, Yes; J2030B: Date of first

screening for shortness of breath: Enter 11-12-25; J2030C: Did the screening indicate the patient had

shortness of breath? Code 0, No and skip to J2050, Symptom Impact Screening.

Rationale: The documentation provides evidence that breathing was screened or assessed. J2030C is

reported as 0, No because the screening indicated that although the patient was breathing shallowly,

there were no signs of distress or concerns from patient/family.

3. During the admission visit, on 01-22-2026, the patient had great difficulty with breathing when walking

to the bathroom and the nurse noted a respiration rate of 30. The patient’s respiration rate decreased to

24 after resting for a few minutes. The nurse documents the findings in the hospice electronic health

record (EHR).

Coding: J2030A: Was the patient screened for shortness of breath? Code 1, Yes; J2030B: Date of first

screening for shortness of breath: Enter 01-22-2026; J2030C: Did the screening indicate the patient had

shortness of breath? Code 1, Yes.

Rationale: The clinician used careful questioning and observation to establish the presence and

severity of shortness of breath. Documentation confirmed the screening for shortness of breath. Thus,

code 1, Yes for J2030A, and continue to J2030B-J2030C, using evidence in the clinical record to report

date and presence or absence of shortness of breath.