O0110H1a. Treatment: IV Medications- On Adm, Step-by-Step
Step-by-Step Coding Guide for Item Set: O0110H1a, Treatment: IV Medications- On Admission
1. Review of Medical Records
Objective: Identify if IV medications were administered upon admission. Key Points:
- Thoroughly review the resident's medical records upon admission for any orders and administration of IV medications.
- Pay special attention to the admitting physician’s orders, nursing admission assessments, and medication administration records (MARs).
- Document the type of IV medication administered, the dosage, frequency, and the duration for which it was ordered.
2. Understanding Definitions
Objective: Clarify what constitutes IV medications. Key Points:
- IV medications refer to drugs delivered directly into the venous circulation via a syringe or intravenous catheter.
- This category includes antibiotics, antivirals, antifungals, hydration fluids, electrolyte replacements, and other medications administered intravenously.
- Understanding the broad range of IV medications and their purposes is crucial for accurate documentation.
3. Coding Instructions
Objective: Accurately code for IV medication use on admission. Key Points:
- Code '1' if any IV medication was administered on the day of admission.
- Ensure coding reflects the administration of the medication, not just the physician's order.
- Include both continuous and intermittent (bolus) IV medications in your coding.
4. Coding Tips
Objective: Ensure clarity and consistency in coding IV medications. Key Points:
- Double-check admission dates and times against medication administration records to ensure accuracy.
- Consult with the nursing or pharmacy staff if there's uncertainty about the categorization of a medication as IV.
- Remember to code based on actual administration rather than plans or orders for IV medication that were not carried out.
5. Documentation
Objective: Maintain detailed and accessible records for IV medication administration. Key Points:
- Document the name, dosage, route (IV), and time of administration for all IV medications given on admission.
- Include any adverse reactions observed or reported following IV medication administration.
- Ensure the continuation of IV medication (if applicable) is clearly documented in the care plan and handover notes.
6. Common Errors to Avoid
Objective: Identify and prevent typical mistakes in documentation and coding. Key Points:
- Omitting to code IV medications because they are routine or perceived as minor (e.g., hydration fluids).
- Confusing orders for IV medication with actual administration, leading to inaccurate coding.
- Failing to update documentation if IV medication orders are canceled or changed.
7. Practical Application
Objective: Reinforce learning with real-world scenarios. Key Points:
- Scenario: A resident is admitted with dehydration and receives an IV hydration therapy on admission. Document and code this scenario, highlighting the medication name, volume, and rate of administration.
- Use case studies in team meetings to discuss the coding of various IV medications administered on admission, emphasizing different types and purposes of IV medications.
- Create a mock chart review exercise focusing on identifying and coding IV medications correctly, incorporating feedback on common errors and best practices.
Please note that the information provided in this guide for MDS 3.0 Item set O0110H1a 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.
