O0110O3c: Treatment: IV Access - Midline - At Discharge, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110O3c: Treatment: IV Access - Midline - At Discharge

1. Review of Medical Records

• Objective: To accurately document the resident’s IV access - Midline status at discharge.
• Steps:
  1. Access Records: Retrieve the resident’s complete medical records, including discharge summaries, nursing notes, and treatment records.
  2. Verify Treatment: Look for documented evidence of Midline IV access, focusing on dates of insertion, maintenance, and removal.
  3. Cross-Reference: Confirm that the IV access information is consistent across different sections of the medical records (e.g., physician orders, nursing documentation).

2. Understanding Definitions

• IV Access - Midline: A type of intravenous access that is inserted into a vein in the arm and extends up to the axilla but does not enter the central veins.
• At Discharge: Refers to the resident’s status at the time of discharge from the facility.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Access item set O0110O3c on the MDS form.
  2. Verify Treatment: Confirm the presence of Midline IV access at the time of discharge.
  3. Code the Item:
  • If Midline IV access was present at discharge, code the item as “1” (Yes).
  • If Midline IV access was not present at discharge, code the item as “0” (No).
  4. Complete Entry: Ensure that all relevant information is accurately documented, including the date of IV access placement and any pertinent notes.

4. Coding Tips

• Ensure Accuracy: Double-check the medical records to confirm the presence of Midline IV access at discharge.
• Document Dates: Ensure that the dates of IV access placement and maintenance are clearly documented.
• Consistency: Verify that the IV access information is consistent across all relevant sections of the resident’s medical records.

5. Documentation

• Required:
  • Medical Records: Comprehensive records, including physician orders, nursing notes, and discharge summaries, confirming the presence of Midline IV access.
  • MDS Form: Accurate completion of item set O0110O3c indicating the presence or absence of Midline IV access at discharge.
  • Supporting Documents: Include any relevant documentation that supports the coding decision (e.g., treatment records).

6. Common Errors to Avoid

• Misdocumentation: Incorrectly documenting the presence or absence of Midline IV access without proper verification.
• Incomplete Records: Missing or incomplete documentation regarding IV access.
• Inconsistent Coding: Discrepancies between the MDS form and other sections of the resident’s medical records regarding IV access.

7. Practical Application

• Example:

  • Resident Background: Mr. John Doe had a Midline IV access inserted during his stay and it remained until discharge.
  • Review Process: Upon review, his medical records include a physician order for Midline IV access, nursing notes documenting its maintenance, and the discharge summary confirming its presence at discharge.
  • Coding Process:
    • Step 1: Access the MDS form and locate item set O0110O3c.
    • Step 2: Verify the presence of Midline IV access at discharge in his records.
    • Step 3: Code the item as “1” (Yes) to indicate the presence of Midline IV access at discharge.
    • Step 4: Document the date of IV access placement and any relevant notes in the MDS form.
  • Documentation: Ensure that the MDS form is consistent with his medical records and includes all supporting documentation.

• Illustration:

  • Provide a sample MDS form showing item set O0110O3c coded as “1” (Yes) with the corresponding supporting documentation.

Please note that the information provided in this guide for MDS 3.0 Item set O0110O3c was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.