Step-by-Step Coding Guide for Item Set: K0710B3. Average Fluid Intake per Day via IV/Tube: Last 7 Days

1. Review of Medical Records

   • Begin by thoroughly reviewing the resident’s medical records for the last 7 days, focusing specifically on IV (intravenous) therapy or tube feeding documentation. Look for detailed records from healthcare providers, dietitians, or nutritionists, and nursing logs that note the volume of fluids administered via these methods.

2. Understanding Definitions

   • Average Fluid Intake per Day via IV/Tube: This measures the mean volume of fluids a resident receives daily through intravenous therapy or tube feeding, calculated over the most recent 7-day period.
   • Last 7 Days: Refers to the week immediately preceding the current date of assessment, focusing on recent fluid intake via IV or tube.

3. Coding Instructions

   • Calculate the average daily fluid intake in milliliters (mL) the resident received via IV or tube over the last 7 days. This involves totaling the volume of fluids administered during this period and dividing by 7.
   • Code: Enter the calculated average daily fluid intake in milliliters (mL). If rounding is necessary, round to the nearest whole number.

4. Coding Tips

   • Accurately track and document all fluid intake via IV or tube, including both nutritional fluids and any medications delivered in liquid form.
   • Review the nursing logs or medical records closely to ensure all instances of IV or tube feeding are accounted for in the 7-day period.

5. Documentation

   • Document the coding decision in the MDS with precision. Also, include in the resident's care plan and medical records detailed information on the IV/tube feeding regimen, specifying the type and volume of fluids provided, and how the average daily fluid intake was calculated.
   • Note any changes in the fluid regimen or the resident’s condition that might have occurred during the last 7 days, impacting fluid intake.

6. Common Errors to Avoid

   • Failing to include all days in the 7-day period, potentially leading to an inaccurate average calculation.
   • Overlooking any sources of fluids received via IV or tube, such as liquid medications, in addition to nutritional solutions.

7. Practical Application

   • Example: Mrs. Taylor, recovering from surgery, required both hydration and nutrition support via tube feeding over the past week. The nursing staff documented a total of 14,000 mL of fluids provided via tube feeding during this 7-day period, which included both hydration solutions and liquid nutrition. To find the average, they divided the total volume by 7, resulting in an average daily fluid intake of 2000 mL via tube. For K0710B3, Mrs. Taylor’s average daily fluid intake via tube for the last 7 days is recorded as 2000 mL. Her care documentation includes this calculation, alongside monitoring for tolerance and the need for adjustments based on her recovery progress.

The Step-by-Step Coding Guide for item K0710B3 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.