K0100A. Swallow disorder: loss liquids/ solids from mouth, Step-by-Step

Step-by-Step Coding Guide for Item Set: K0100A. Swallowing Disorder: Loss of Liquids/Solids from Mouth

1. Review of Medical Records

   • Begin by thoroughly reviewing the resident's medical records, focusing on assessments and notes related to swallowing, nutrition, and speech therapy evaluations. Look for any documented instances of swallowing difficulties, including loss of liquids or solids from the mouth during meals or while drinking. Special attention should be paid to notes from speech-language pathologists, nutritionists, and nursing observations during mealtime.

2. Understanding Definitions

   • Swallowing Disorder: Difficulties in the process of swallowing, which may include problems in the oral phase (chewing and preparing food in the mouth) and the pharyngeal phase (moving food from the mouth to the esophagus).
   • Loss of Liquids/Solids from Mouth: A specific symptom of a swallowing disorder where the resident cannot contain food or liquid in their mouth, leading to spillage from the mouth before swallowing.

3. Coding Instructions

   • Code 0: No - If the resident does not exhibit loss of liquids or solids from the mouth.
   • Code 1: Yes - If the resident has documented evidence or observation of losing liquids or solids from their mouth due to swallowing difficulties.
   • Determine the presence of this symptom by reviewing medical documentation and through direct observation during meals.

4. Coding Tips

   • Ensure observations are made across several meals to account for variability in the resident's condition or meal type.
   • Collaborate with speech-language pathologists or nursing staff who have direct mealtime observation experiences with the resident for accurate coding.

5. Documentation

   • Document your coding decision in the MDS accurately. In the resident's care plan and medical record, include detailed descriptions of observed swallowing difficulties, specifically noting any loss of liquids or solids from the mouth. This should include the frequency of occurrences, types of foods or liquids most affected, and any interventions attempted.

6. Common Errors to Avoid

   • Coding based on a single meal observation without considering variations in the resident’s performance across different times or types of meals.
   • Overlooking the symptom if it appears mild or intermittent, not recognizing its potential impact on the resident's nutritional status and risk of aspiration.

7. Practical Application

   • Example: Mrs. Smith, a resident with a neurological condition affecting her muscle control, has been observed by nursing staff and a speech-language pathologist to frequently lose liquids from her mouth when attempting to drink. This occurs most often with thin liquids and less so with thicker consistencies or solids. The interdisciplinary team implements strategies such as thickening her liquids and closely monitoring her during meals. For K0100A, Mrs. Smith would be coded as "1" for Yes, indicating a loss of liquids/solids from the mouth. Detailed documentation supports this coding, including descriptions of the observations and the interventions in place to mitigate the risk.

The Step-by-Step Coding Guide for item K0100A in MDS 3.0 Section K 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.