M0100C. Risk determination: clinical assessment, Step-by-Step

Step-by-Step Coding Guide for Item Set: M0100C. Risk Determination: Clinical Assessment

1. Review of Medical Records

   • Initiate with an exhaustive review of the resident’s medical records to find documentation of clinical assessments related to skin integrity. This includes physician’s notes, nursing assessments, and any other clinical evaluations focusing on skin condition, potential risk factors for skin breakdown, and overall health status affecting skin integrity.

2. Understanding Definitions

   • Clinical Assessment: A comprehensive evaluation conducted by healthcare professionals using their clinical judgment, without necessarily relying on formal, standardized tools. It involves examining the skin, evaluating risk factors (like immobility, incontinence, nutritional status), and identifying any signs that may indicate a risk for skin breakdown or pressure ulcers.

3. Coding Instructions

   • Code 0: No - If no clinical assessment related to skin integrity risk has been conducted on the resident.
   • Code 1: Yes - If a clinical assessment has been completed, documenting the healthcare professional’s judgment on the resident's risk for skin breakdown or pressure ulcers.
   • Make the coding decision based on documented clinical assessments indicating an evaluation of skin integrity risk.

4. Coding Tips

   • Look for detailed notes that reflect the healthcare professional’s observations, judgment, and any recommendations for preventing skin breakdown, even if a formal, standardized tool was not used.
   • Ensure that clinical assessments are conducted at regular intervals and documented clearly, especially for residents with known risk factors for skin breakdown.

5. Documentation

   • Accurately document the coding decision in the MDS. In the resident’s care plan and medical records, include comprehensive notes on the clinical assessment findings, detailing observations related to skin integrity, identified risk factors, and any proposed interventions or preventive measures.
   • Document the qualifications of the healthcare professional conducting the assessment and the rationale behind their judgments and recommendations.

6. Common Errors to Avoid

   • Misinterpreting general health assessments that do not specifically evaluate skin integrity or risk for breakdown as clinical skin integrity assessments.
   • Overlooking or inadequately documenting informal clinical judgments or observations that indicate a risk for skin integrity issues.

7. Practical Application

   • Example: Mr. Sanchez, a resident with diabetes and reduced mobility, was evaluated by the nursing staff as part of his routine care. The nurse noted dry skin, a history of previous skin tears, and his limited ability to reposition independently. Based on these clinical observations, the nurse identified Mr. Sanchez as at risk for skin breakdown. For M0100C, Mr. Sanchez is coded as "1" for Yes, indicating a clinical assessment was conducted. His care documentation includes the nurse’s observations, the identified risk factors, and the preventive measures initiated, such as increased skin moisturizing, regular skin inspections, and a scheduled repositioning plan.

The Step-by-Step Coding Guide for item M0100C in MDS 3.0 Section M 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.