Step-by-Step Coding Guide for Item Set: K0710B2. Average Fluid Intake per Day via IV/Tube: While a Resident

1. Review of Medical Records

   • Begin by examining the resident's medical records throughout their stay, focusing on periods that include IV (intravenous) therapy or tube feeding. Look for documentation from healthcare providers, dietitians, or nutritionists, and nursing logs that record the volume of fluids administered via IV or tube.

2. Understanding Definitions

   • Average Fluid Intake per Day via IV/Tube: The mean volume of fluids a resident receives per day through intravenous therapy or tube feeding, calculated over the period of their residency excluding the admission and discharge phases.
   • While a Resident: This refers to the period after the resident's initial admission phase and before their discharge, focusing on the ongoing care and treatment they receive.

3. Coding Instructions

   • Calculate the average daily fluid intake in milliliters (mL) the resident received via IV or tube. This involves summing the total volume of fluids received over a specified period and dividing by the number of days in that period.
   • Code: Enter the average daily fluid intake in milliliters (mL). If necessary, round to the nearest whole number.

4. Coding Tips

   • Ensure accurate tracking and documentation of all fluid intake via IV or tube, including both nutritional fluids and medications delivered in liquid form.
   • Consider any changes in fluid requirements or regimen adjustments throughout the resident's stay that could affect the average calculation.

5. Documentation

   • Accurately document the coding decision in the MDS. In the resident's care plan and medical record, include detailed notes on the IV/tube feeding regimen, specifying the type and volume of fluids provided, and the method used to calculate the average daily fluid intake.
   • Record any relevant healthcare provider orders, dietitian recommendations, or changes in the resident's condition that influenced fluid intake strategies.

6. Common Errors to Avoid

   • Neglecting to account for days when the resident did not receive IV or tube feeding, which could inaccurately inflate the average fluid intake.
   • Overlooking the inclusion of all sources of fluids received via IV or tube, such as medications in liquid form, in addition to nutritional solutions.

7. Practical Application

   • Example: Mr. Edwards, who has been a resident for 30 days due to complications from chronic heart failure, requires careful fluid management. During his stay, he received an average of 1000 mL of fluids daily via IV, including medications and nutritional supplements. To calculate this, the nursing staff documented a total of 30,000 mL of fluids administered over 30 days. For K0710B2, Mr. Edwards's average daily fluid intake via IV/tube is recorded as 1000 mL. His care plan reflects this fluid management strategy, including monitoring for signs of fluid overload and adjustments to his IV fluid regimen based on his heart failure status.

The Step-by-Step Coding Guide for item K0710B2 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.