Step-by-Step Coding Guide for P0100F: Restraint Used in Chair/Out of Bed Limb Restraint

1. Review of Medical Records

Start by examining the resident's medical records for any documentation of physical restraints used during the 7-day look-back period. Look for physician orders, nursing notes, and documentation from nursing assistants or other care team members that indicate the use of limb restraints while the resident is in a chair or out of bed.

2. Understanding Definitions

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

Limb Restraints: These include devices that restrict movement of any part of an upper extremity (hand, arm, wrist) or lower extremity (foot, leg) that either limits freedom of movement or access to the body.

3. Coding Instructions

• Code 0 (Not Used): If the limb restraint was not used during the 7-day look-back period.
• Code 1 (Used Less Than Daily): If the limb restraint was used but not on a daily basis during the observation period.
• Code 2 (Used Daily): If the limb restraint met the definition and was used daily during the look-back period.

4. Coding Tips

• Evaluate the resident's ability to remove the restraint voluntarily.
• The classification of a device as a restraint depends on its effect on the resident, not the intent behind its use.
• Always ensure there's a medical symptom that supports the use of the restraint, documented by a physician.

5. Documentation

• Document the specific medical symptom that justifies the use of the restraint.
• Record the type of restraint used, its frequency, and the duration of use.
• Include a care plan aiming at restraint reduction or elimination, where possible.

6. Common Errors to Avoid

• Misclassifying devices that are not intended as restraints (e.g., supportive devices for medical conditions).
• Failing to document the medical rationale behind the use of restraints.
• Not updating the care plan to reflect changes in the resident's condition or response to the restraint.

7. Practical Application

• A resident with uncontrolled movements due to a neurological condition may have a wrist restraint applied while in a communal area to prevent self-harm. This restraint is used under physician orders, with specific documentation on the medical need and regular assessments for potential reduction or discontinuation.

The Step-by-Step Coding Guide for item P0100F 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.