H0200A. Urinary toileting program: has been attempted

Step-by-Step Coding Guide for Item Set: H0200A. Urinary Toileting Program: Has Been Attempted

1. Review of Medical Records

   • Start by thoroughly reviewing the resident’s medical records to identify any mention of a urinary toileting program. Look for documentation in nursing care plans, physical therapy assessments, and physician's orders. Notes regarding the initiation, progress, modifications, and outcomes of any toileting program should be particularly noted.

2. Understanding Definitions

   • Urinary Toileting Program: A structured approach to managing urinary incontinence or retention that may include scheduled toileting, prompted voiding, or bladder training. The goal is to improve bladder control or ensure regular emptying of the bladder to prevent incontinence.
   • Has Been Attempted: Indicates that a urinary toileting program was initiated for the resident at some point during their stay, regardless of the outcome or current status of the program.

3. Coding Instructions

   • Code 0: No - If no urinary toileting program has been initiated for the resident.
   • Code 1: Yes - If a urinary toileting program has been attempted during the resident's stay.
   • Assess whether a toileting program was initiated based on the review of medical records and consultation with the care team.

4. Coding Tips

   • Confirm the attempt of a toileting program through direct discussion with nursing staff or caregivers involved in the resident's daily care routines.
   • Note the specifics of the program, such as the type (prompted voiding, scheduled toileting), frequency, and any assistive devices or strategies used.

5. Documentation

   • Document your coding decision in the MDS. In the resident's care plan and medical record, include detailed notes on the toileting program attempted, including objectives, strategies employed, resident's participation and response, and any observed outcomes or reasons for discontinuation.

6. Common Errors to Avoid

   • Misinterpreting casual or as-needed toileting assistance as a structured toileting program.
   • Overlooking documentation or care team input that confirms the attempt of a toileting program.

7. Practical Application

   • Example: Mrs. Ellis experiences urinary incontinence due to mobility issues. The care team initiated a prompted voiding program, scheduling toileting every 2 hours during the day. Despite the team's efforts and Mrs. Ellis's participation, the program saw limited success. For H0200A, Mrs. Ellis would be coded as "1" for Yes, indicating that a urinary toileting program was attempted. The care plan includes details of the program's implementation, her response, and considerations for future interventions based on the outcomes observed.

The Step-by-Step Coding Guide for item H0200A in MDS 3.0 Section H is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.