Step-by-Step Coding Guide for O0500: Restorative Nursing Programs

1. Review of Medical Records

• Examine the resident's medical records for any mention of participation in restorative nursing programs.
• Look for notes from nursing, therapy, and medical staff regarding the resident's capabilities, participation levels, and progress in any restorative programs.

2. Understanding Definitions

• Restorative Nursing Programs: These are nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept encompasses activities that help maintain the resident's highest level of physical, mental, and psychosocial functioning.
• Active Participation: The resident's engagement in restorative nursing programs, which should be structured, consistent, and documented.

3. Coding Instructions

• Code for each restorative nursing program in which the resident actively participates. Active participation is defined by involvement in a program at least 6 days a week for at least two consecutive weeks.

4. Coding Tips

• Verify the frequency and duration of the resident's participation in each program.
• Collaboration with interdisciplinary team members can provide insights into the resident's engagement and progress.

5. Documentation

• Document detailed information about each restorative nursing program, including objectives, frequency of sessions, specific activities, and the resident's response to the program.
• Update the resident's care plan and progress notes regularly to reflect participation in restorative nursing programs.

6. Common Errors to Avoid

• Failing to code for a program because of incomplete documentation or misunderstanding of the definition of active participation.
• Overlooking short-term interventions that meet the criteria for restorative nursing programs.

7. Practical Application

• For a resident participating in a restorative ambulation program to maintain walking abilities, ensure documentation reflects the program's goals, frequency, and the resident's progress or challenges.

The Step-by-Step Coding Guide for item O0500 in MDS 3.0 Section O is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that 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.