P0100H. Restraint used in chair/ out of bed: other

Step-by-Step Coding Guide for P0100H. Restraint used in chair/ out of bed: other

Step 1: Review of Medical Records

Begin by examining the resident's medical records, including physician orders, nursing notes, and documentation from nursing assistants. Look for evidence of physical restraint use outside of bed or in a chair, paying special attention to non-standard restraints that might not fit typical categories but are used for the resident's safety.

Step 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 they cannot remove easily, which restricts freedom of movement or normal access to one’s body. This includes any item that is not a standard restraint if it meets the criteria of restricting movement for safety purposes.

Step 3: Coding Instructions

For P0100H, code the use of any restraint not listed in previous sections but used to restrict the resident's movement for safety while in a chair or out of bed. This includes innovative or uncommon methods devised for specific, individual needs, ensuring resident safety without fitting into standard restraint categories.

Step 4: Coding Tips

• Focus on the resident’s ability to remove the restraint and its impact on their movement.
• Consider the restraint's purpose: safety versus convenience.
• Document the rationale for its use, aligning with care objectives and the resident’s specific needs.

Step 5: Documentation

Ensure documentation includes:

• A physician’s order for the specific type of restraint used, including "other" restraints.
• The medical symptom or safety concern necessitating its use.
• An ongoing care plan outlining the goal of minimizing or eliminating the restraint.

Step 6: Common Errors to Avoid

• Failing to identify and code non-standard restraints used for safety.
• Misinterpreting restraint use as convenience rather than a necessity.
• Inadequate documentation of the medical justification and care planning for restraint use.

Step 7: Practical Application

Consider a resident with complex behavioral symptoms leading to unsafe wandering. A specially designed chair that prevents unsafe wandering without a standard restraint category could be considered under P0100H. Ensure proper documentation, including the safety rationale, physician orders, and efforts for less restrictive alternatives.

The Step-by-Step Coding Guide for item P0100H 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.