Step-by-Step Coding Guide for Item Set A0310F: Entry/Discharge Reporting

This guide provides a detailed approach for accurately coding and documenting the entry/discharge reporting in the MDS 3.0, specifically within item A0310F.

1. Review of Medical Records

• Objective: Identify if the MDS is being completed for entry or discharge purposes.
• Key Points:
  • Examine the resident's admission and discharge dates in the medical records.
  • Confirm whether the MDS assessment corresponds with the resident's entry into the facility or discharge from the facility.

2. Understanding Definitions

• Objective: Clarify what is meant by "Entry/Discharge Reporting."
• Key Points:
  • Entry Reporting: Documentation completed upon a resident's admission to the facility.
  • Discharge Reporting: Documentation required when a resident exits the facility, either temporarily or permanently.

3. Coding Instructions

• Objective: Guide on correctly coding entry or discharge status.
• Key Points:
  • For entry reporting, use the appropriate code to indicate the resident's admission (e.g., "01" for admission reporting).
  • For discharge reporting, select the code that best describes the resident's discharge circumstances (e.g., "10" for discharge home, "11" for discharge to hospital).

4. Coding Tips

• Double-check the dates of entry or discharge to ensure the correct reporting period is being coded.
• Be aware of different codes for various types of discharge, such as temporary or permanent, and code accordingly.

5. Documentation

• Objective: Maintain accurate records to support the entry/discharge coding.
• Key Points:
  • Document the date of entry or discharge in the resident’s medical record, along with any relevant details such as the destination after discharge.
  • Keep a copy of the completed MDS assessment with the entry/discharge coding in the resident’s file.

6. Common Errors to Avoid

• Incorrectly coding the type of discharge or failing to document a discharge when the resident leaves the facility.
• Overlooking the need to complete a discharge assessment for residents who leave the facility temporarily.

7. Practical Application

• Scenario: Mr. John Doe is discharged from the facility to a hospital following a sudden illness. The MDS Coordinator reviews Mr. Doe’s medical record, noting the date of discharge. In item A0310F, the coordinator selects the code for "discharge to hospital" and ensures that the date of discharge is accurately documented in both the MDS and the resident’s medical record. This process helps maintain compliance with reporting requirements and assists in accurate record-keeping for facility occupancy and billing.

The Step-by-Step Coding Guide for item A0310F 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.