Archived Posts

Coding Section P of the MDS 3.0, Restraints
Posted by LTCS on June 5, 2013

Sad Woman in Wheelchair Director of Nursing BookThe intent of section P is to record the frequency over the 7-day look-back period that the resident was restrained by any of the listed devices at any time during the day or night. 

Physical restraint use in long term care facilities has decreased from more than 40% in the 1980s to 10%. 

Routine restraint use does not lower the risk of falls or fall injuries, but can actually increase their occurrence. Most long term care facilities have seen a drop in fall-related injuries since decreasing restraint use. 

P Restraints

Restraints CAA Module and Care Area Assessment 

Coding Section O, Special Treatments and Procedures
Posted by LTCS on June 4, 2013

Restorative Nursing ProgramThe intent of section O is to:

Identify any special treatments, therapies, or programs that the resident received in the specified time period.

Determine the extent to which the resident receives nursing rehabilitation or restorative services from other than specialized therapy staff.

Determine the rate of vaccination and causes for non-vaccination for Influenza and Pneumococcal immunizations. 

Entries in Section O effect the higher RUG IV Categories. 

Skilled Medicare Charting and nursing care plans associated with section O entries include:

Diabetes

Dialysis

IV Medication

Occupational Therapy

Oxygen Use

Physical Therapy

Respiratory Therapy

Restorative Nursing

Speech Therapy

Suctioning

Tracheostomy Care 

O Special Treatments and Programs

Skilled Charting Guidelines – Cardiac Care

Skilled Charting Guidelines – Tube Feeding

Coding Section N of the MDS 3.0, Medications
Posted by LTCS on June 3, 2013

Medication Care PlanThe intent of section N is to record the number of days, during the last 7 days (or since admission/reentry if less than 7 days) that any type of injection, insulin, and/or select oral medications were received by the resident.

Care Areas that may be triggered in section N are Psychotropic Drug Use and Falls.

Entries in the section effect the RUG IV Category, Special Care High.

The need for Skilled Charting on Diabetes and IV Medication may be assessed from section N item entries.

Medication care plans that may be generated from section N include Antianxiety, Anticoagulant, Antidepressant, Antipsychotic, Polypharmacy, Hypnotic, Pain Medication, and Psychotropic. 

N Medications

Coding Section M of the MDS, Skin Conditions
Posted by LTCS on May 29, 2013

Skin CareThe intent of section M is to determine the condition of the resident’s skin, identify the presence, stage, type, and number of ulcers, and document other problematic skin conditions.

It also documents if pressure ulcers were developed since admission to the facility, documents prevention, treatment, and management of skin problems, and documents the healing progress of pressure ulcers.

RUG IV categories that are affected by section M entries are Special Care Low and Clinically Complex.

Certain entries will trigger a need for Skilled Charting on Wound Care.

Care Plans that may be generated from section M are Peripheral Vascular Disease and Skin Breakdown.

Section M Skin Conditions