Step-by-Step Coding Guide for Item Set A0310E: First Assessment Since Most Recent Entry

This guide will help ensure accurate coding and documentation for item A0310E, indicating whether the current MDS assessment is the first assessment since the resident's most recent entry into the facility.

1. Review of Medical Records

• Objective: Determine if the current assessment is the first since the resident's latest admission.
• Key Points:
  • Examine the resident's admission records and any previous MDS assessments completed since their most recent entry into the facility.
  • Verify the date of the most recent entry and any subsequent MDS assessments to confirm if the current MDS is indeed the first assessment following this entry.

2. Understanding Definitions

• Objective: Clarify what "First Assessment Since Most Recent Entry" means.
• Key Points:
  • This item identifies whether the current MDS assessment is the initial assessment completed after the resident's latest admission or reentry to the facility, not including readmissions from hospital stays where the resident returns to the same facility.

3. Coding Instructions

• Objective: Provide guidelines for accurately coding A0310E.
• Key Points:
  • Code 0: No, this is not the first assessment since the most recent entry.
  • Code 1: Yes, this is the first assessment since the most recent entry.

4. Coding Tips

• Carefully review the resident's history of entries and discharges to accurately determine if the current assessment is the first since their latest return to the facility.
• Be particularly attentive to details around hospital readmissions or transfers from other care settings that might affect the determination of "most recent entry."

5. Documentation

• Objective: Ensure comprehensive documentation to support the coding of A0310E.
• Key Points:
  • Document the date of the resident's most recent entry into the facility in their medical record, along with any subsequent MDS assessment dates.
  • Maintain clear records of any readmissions or transfers to support the determination made in A0310E.

6. Common Errors to Avoid

• Misinterpreting a readmission from a hospital stay as a new entry, leading to incorrect coding of the assessment as the first since the most recent entry.
• Overlooking previous MDS assessments conducted after the resident's latest admission or reentry.

7. Practical Application

• Scenario: Mrs. Jones was admitted to the facility on April 1. She was hospitalized for a brief period in May and returned to the facility on May 15. The RN Coordinator is preparing to complete an MDS assessment scheduled for June 5. Upon reviewing Mrs. Jones's records, it's determined that no MDS assessments have been completed since her return on May 15. Therefore, the RN Coordinator correctly codes A0310E as "1," indicating that the upcoming June 5 assessment is the first since Mrs. Jones's most recent entry.

The Step-by-Step Coding Guide for item A0310E in MDS 3.0 Section A 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.