Step-by-Step Coding Guide for P0100. Physical Restraints

1. Review of Medical Records

• Start by examining the resident's medical records, including physician orders, nursing notes, and physical therapy reports, to identify any use of physical restraints.
• Pay special attention to the period known as the 7-day look-back period to capture all instances of restraint use.

2. Understanding Definitions

• Physical Restraints: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body.

3. Coding Instructions

• Code for each type of restraint used:
  • P0100A: Bed rails
  • P0100B: Trunk restraint
  • P0100C: Limb restraint
  • P0100D: Other restraint
• Code frequency of use for each restraint:
  • 0: Not used
  • 1: Used less than daily
  • 2: Used daily

4. Coding Tips

• Ensure accurate differentiation between devices used for medical immobilization, support for physical function, and those considered restraints.
• Verify with the care team the purpose of each device to decide if it qualifies as a restraint.
• Consider resident interviews or family discussions to clarify any instances of restraint use.

5. Documentation

• Clearly document the clinical rationale for each restraint used, including specific safety or medical reasons.
• Record any resident or family discussions regarding restraint use, including consents or objections.
• Include plans for restraint reduction or alternatives tried in the resident's care plan.

6. Common Errors to Avoid

• Misclassifying safety devices as restraints (e.g., side rails used solely for mobility assistance).
• Overlooking the occasional use of restraints, which should be coded even if used less than daily.
• Failing to update the MDS to reflect changes in restraint use within the 7-day look-back period.

7. Practical Application

• Example 1: A resident uses side rails for safety due to a high risk of falling out of bed. Coding: P0100A = 2 (used daily).
• Example 2: A resident has a lap belt in their wheelchair that they can release independently. Coding: Not considered a restraint, thus not coded in P0100.
• Example 3: A resident occasionally wears wrist restraints to prevent pulling at IV lines. Coding: P0100C = 1 (used less than daily).

The Step-by-Step Coding Guide for item P0100 in MDS 3.0 Section P 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.