H0200C. Urinary toileting program: current program/trial, Step-by-Step

Step-by-Step Coding Guide for Item Set: H0200C. Urinary Toileting Program: Current Program/Trial

1. Review of Medical Records

   • Initiate the process by examining the resident's medical records in detail, specifically searching for any current or ongoing urinary toileting program or trial. Look for care plans, nursing notes, and therapy assessments that detail the initiation, objectives, strategies, and progress of the toileting program.

2. Understanding Definitions

   • Urinary Toileting Program: A structured approach, including prompted voiding, bladder training, or scheduled toileting, aimed at managing urinary incontinence or promoting bladder health.
   • Current Program/Trial: Refers to a toileting program that is actively being implemented during the assessment period for the resident.

3. Coding Instructions

   • Code 0: No - If the resident is not currently participating in a toileting program.
   • Code 1: Yes - If the resident is currently engaged in a toileting program.
   • Assess whether a toileting program is actively in place for the resident based on the latest documentation and consultation with caregiving staff.

4. Coding Tips

   • Verify the current status of the toileting program through direct observation or discussions with the nursing staff and caregivers. Documentation might not always be up-to-date, so firsthand information is invaluable.
   • Understand the specific goals and strategies of the toileting program to accurately code its presence and effectiveness.

5. Documentation

   • Accurately document the coding decision in the MDS. Additionally, include comprehensive notes in the resident’s medical record detailing the current toileting program, including its frequency, specific interventions used (such as timed toileting or bladder training exercises), and any modifications made based on the resident's progress or challenges.

6. Common Errors to Avoid

   • Coding a resident as not participating in a toileting program based solely on the absence of recent documentation without consulting the care team for updates.
   • Confusing past toileting program trials with current efforts, leading to inaccurate coding.

7. Practical Application

   • Example: Mrs. Thompson, who experiences stress incontinence, is enrolled in a bladder training program that includes scheduled toileting every 3 hours during the day and pelvic floor exercises. The program was initiated two weeks prior to the assessment period and is noted in her care plan, with ongoing evaluations by the nursing staff documented in her medical record. Based on this information, Mrs. Thompson would be coded as "1" for Yes under H0200C, indicating her active participation in a current toileting program. Detailed documentation reflects the program's specifics, her adherence, and any observed improvements or challenges.

The Step-by-Step Coding Guide for item H0200C 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.