Step-by-Step Coding Guide for Item Set A0050: Type of Record

1. Review of Medical Records

• Objective: Determine the type of record being completed for the resident.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including admission forms, transfer records, discharge summaries, and any previous assessments.
  2. Identify Documentation of Type of Record: Look for specific documentation that indicates whether the record is for admission, annual assessment, significant change, or another type of assessment.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across different parts of the medical records.

2. Understanding Definitions

• Type of Record: Refers to the specific purpose or event prompting the completion of the record. Common types include:
  • Admission Record: Completed when a resident is admitted to the facility.
  • Annual Assessment: Completed yearly to evaluate the resident’s ongoing needs and care plan.
  • Significant Change in Status: Completed when there is a major change in the resident’s health or functional status.
  • Quarterly Assessment: Completed every quarter to update the resident’s status and care plan.
  • Discharge Record: Completed when a resident is discharged from the facility.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm the type of record being completed based on the documentation in the medical records.
  2. Verify Documentation: Ensure the type of record is clearly documented and corresponds with the reason for completing the assessment.
  3. Code Appropriately: Enter the appropriate code for the type of record:
     • 1: Admission Record
     • 2: Quarterly Assessment
     • 3: Annual Assessment
     • 4: Significant Change in Status
     • 5: Discharge Record

4. Coding Tips

• Accurate Identification: Ensure the type of record is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology when documenting and coding the type of record.
• Consult Records: Cross-check with other records and assessments to verify the type of record being completed.

5. Documentation

• Required:
  • Admission Forms: Document details of the resident’s admission, if applicable.
  • Assessment Forms: Include information about the type of assessment being completed (e.g., annual, quarterly).
  • Care Plans: Document changes in the care plan related to the type of record.
  • Discharge Summaries: Include details if the record is a discharge record.
  • Significant Change Documentation: Provide evidence of any significant changes in the resident’s status if applicable.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the type of record through multiple sources in the medical records.
• Incomplete Documentation: Make sure all relevant documentation is included and accurately reflects the type of record.
• Assumptions: Do not assume the type of record without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Jane, an 80-year-old resident, is being reassessed due to a significant change in her health status.
  • Steps:
    1. Review Records: The nurse reviews Jane’s medical records, noting the documentation of a significant change in her health status.
    2. Identify Type of Record: It is confirmed that the assessment is being completed due to a significant change in status.
    3. Document and Code: The nurse documents the details in Jane’s records and codes A0050 as "4" (Significant Change in Status).
  • Outcome: Jane’s type of record is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set A0050 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.